GLOBAL PSYCHIATRY

Objective:  Body dysmorphic disorder (BDD) is an underdiagnosed condition among the general population with significant associated morbidity and mortality. Symptoms of BDD include worrying excessively about a particular part of the body, repeatedly checking oneself in the mirror and attempting to cover up particular areas of the body.
Aim: To determine the prevalence of BDD within the global population. To perform a further subgroup analysis to identify groups that have a higher prevalence than the general population. To assess the modalities of diagnosis BDD and its relative abundance.
Methods: A systematic review using the PubMed database using the search criteria ‘BDD’ or ‘body dysmorphic disorder’ and ‘prevalence’ or ‘incidence’ from 1 January 1990 to 1 January 2020. 591studies were found, 81 of which were eligible and included in the study. Prevalence was calculated for the global population and subgroups, student, dermatology, surgical and psychiatric patients.
Results: The ranges of prevalence within studies were as follows; within the general population, the prevalence of BDD ranged from 0.5-3.2% (n=8). It was 1.3-5.8% (n=8) in student cohorts, 4.9- 21.1% (n=12) in general dermatology cohorts, 1.3%-5.8% (n=8) in a student population, 0-54.3% (28) in psychiatric cohorts and 2.9- 57% (n=15) in cosmetic surgery cohorts.
Conclusion: Studies found had low heterogenicity. However, there was variation in diagnostic criteria and methods of data collection. This study shows that a significant number of people suffer from BDD. Due to the fact that people with BDD often don’t seek help, this number is likely an underestimation. This study identified subgroups of the population that have a higher prevalence of BDD. Targeted screening of individuals in high-risk cohorts, as well as further clinician education, may be of benefit to help aid early recognition and diagnosis. Additionally, structured clinical interviews for DSM (the Diagnostic and Statistical Manual of Mental Disorders), also known as SCID, were the most common and appear to be more effective than normal interviews at identifying individuals with BDD.

The sensationalised and harmful content of media reporting of suicide is a modifiable risk factor for suicide and suicidal behaviour. Although the World Health Organization (WHO) has published guidelines for responsible media reporting of suicide to prevent suicide contagion, the uptake of these recommendations across media outlets remains limited due to several barriers such as the motivation of stakeholders, inadequate training of media personnel, and a lack of real-time monitoring by the government. In this report, we suggest that artificial intelligence (AI) based models, can be used to address barriers to guideline adherence and improve the quality of media reporting. It is our understanding that the development and implementation of AI-based models or tools can assist in improving adherence to suicide reporting guidelines. We propose a hybrid model that incorporates steps that can be taken at different levels of the media news communication cycle. The algorithmic approach can help in simultaneously processing large amounts of data while also facilitating the design of article structures and placement of key information recommended by media reporting guidelines. The potential benefits of the AI-based model to the various stakeholders and the challenges in implementation are discussed. Given the positioning of responsible media reporting of suicide as a key population-level suicide prevention strategy, efforts should be made to develop and evaluate AI-based models for improving the quality of media reporting in different national or international settings. 

Background:  The COVID-19 pandemic has devastatingly affected the entire world and destroyed the equilibrium of every sphere of life. Like other groups of people, medical students of Nepal have been facing the conditions of lockdown and social isolation that have arisen because of the pandemic.
Objective: We aimed to see the relationship of perceived isolation and resilience with self-rated mental health among undergraduate medical students in Nepal.
Materials and methods: A web-based online survey was carried out in July 2020 using a semi-structured questionnaire in Google form. Data analysis was performed in SPSS vs 20. Ordered logistic regression analysis was performed to examine the effects of perceived isolation, resilience and background characteristics on self-rated mental health.
Results: Out of 515 participants, 44.9% were male.31.4% reported having fair/poor mental health status and 21.9% reported feeling stressed often due to the COVID-19 pandemic. An increment of 1SD in perceived isolation is associated with about a 5% reduction in the odds of having better mental health (exp (−0.048) = 0.95; p=0.026). Similarly, an increment of 1SD in resilience is associated with about 13% lower odds of having better mental health (exp (−0.149) = 0.862 ; p<0.001).
Conclusion: This study is an early step towards the assessment of perceived isolation and mental health among undergraduate medical students amid the COVID-19 pandemic in Nepal. There is a need to conduct regular counselling sessions and strengthen the coping skills of medical students duringthe pandemic.

Objective:  Alcohol use disorder (AUD) is a global health concern. Patients with AUDs often relapse. Various psychosocial factors, as well as cognitive factors, determine relapse. Failure of response inhibition is often associated with relapse. This study aimed to evaluate the association of craving and relapse precipitants with executive function in AUD.
Materials and methods: The study was conducted in the outpatient setting of a tertiary care hospital in North India (between September 2017 to August 2018) on patients with AUD, who presented with a recent relapse.
A total of 46 adult patients with AUD, who relapsed after a quit attempt were enroled in the study. Cross-sectional assessment of relapse precipitants (by using relapse precipitant inventory), craving (by using the obsessive-compulsive drinking scale (OCDS)), and executive function (EF) (by using the Wisconsin Card Sorting Test (WCST)) was done along with various socio-demographic and clinical variables.
Results: The mean age of onset of alcohol use was 21.48±4.25years and the mean duration of alcohol use was 15.13±7.70 years. The average number of relapses in the study population was 3.59±2.06. There is a significant positive correlation between a negative mood state (as a relapse precipitant) and total relapse score with craving. There is a significant association of relapse and craving with deficits of EF (perseverative and non-perseverative errors). Similarly, lessened cognitive vigilance also significantly correlate with EF deficits resulting in a relapse of AUD.
Conclusion: There is a close association of craving, and relapse with deficits of EF, in AUD. Craving and relapse in AUD may be the result of deficits in EF. Future research addressing the cognitive deficits may help in the prevention of craving and relapse.

Background: Stigma towards the patient of coronavirus disease (COVID-19) has been reported in various media reports, including negative behaviour among health care workers (HCWs) towards COVID-19 patients. Moreover, the negative behaviour of HCWs towards COVID-19 patients could affect the professional quality of life of these HCWs.
Objective: We aimed to assess stigma related to COVID-19 patients among HCWs and explore its impact on their professional quality of life during COVID-19 pandemic in Nepal.
Methods: An online cross-sectional study was carried out among 421 HCWs (health assistants 35.6%, nurses 33%, doctors 23.3% and paramedics 8.1%), 52.7% female, working in health facilities in Nepal. The measures included background characteristics, stigma in terms of - discrimination towards COVID-19 patients, acceptance of COVID-19 patients and fear of COVID-19, and professional quality of life in terms of - work satisfaction, burnout and fatigue. Descriptive and inferential statistics were utilised to analyze the data in SPSSvs20.
Results: While around two-third of the study participants showed discriminating attitude towards COVID-19, a half showed negative attitude towards acceptance of COVID-19 patients, and a fifth reported attitude of fear of COVID-19.
Multivariable regression analysis indicated that while presence of fear of COVID-19 was associated with low satisfaction, low burnout, and low fatigue; attitude of acceptance of COVID-19 patients was associated with low burnout and low fatigue; and attitude of discrimination towards COVID-19 patients was associated with only low satisfaction.
Conclusion: Strategies directed towards - reducing fear and discrimination towards COVID-19 patients, and enhancing positive attitude of acceptance towards COVID-19 patients among HCWs, and thus, creating enabling environment for reducing their burnout and fatigue, and increasing work satisfaction are recommended.

Abstract
Objective: Perioperative anxiety is described as an uncomfortable, tense or unpleasant mood at any point in the surgical
journey. It can alter the way patients’ deal with the surgical experience and think about surgical treatments in the future.
This systematic review aims to investigate the methods of diagnosing perioperative anxiety and assess the prevalence of the
condition within the global paediatric population undergoing operations.
Materials and methods: The systematic review was conducted in accordance with the PRISMA Checklist (a 27-item checklist to
address introduction, methods, results and discussion with a systematic review). Medline and Scopus databases were searched.
Two independent reviewers determined which papers were suitable for inclusion. Inclusion was determined by the mention
of prevalence of operative-related anxiety, in a population under 18 years old and patients that were undergoing an operation
in a hospital setting. Initially, 48 papers were found and, after screening, a total of 12 eligible studies were included. Data was
extracted on the method of diagnosis of anxiety, the prevalence of perioperative anxiety, the time of assessment and the age
of the cohort. Cochrane bias assessment was used to assess the presence of types of bias in randomised control trials (RCTs)
included and the risk of bias in non-randomised studies of interventions tool in each non-RCTs.
Results: 83% (n=10) studies used the modified Yale Preoperative Anxiety Scale (mYPAS) for diagnosis.‌‌ The overall average
prevalence of perioperative anxiety in each paediatric cohort undergoing surgery was 42.1% (95% CI 30.5 - 53.7). There was
not sufficient evidence to support a relationship between the age of the patient groups, the time of the anxiety assessment and
the prevalence of the perioperative anxiety.
Conclusion: Paediatric anxiety remains a significant factor affecting over a third of all children who undergo operations.
The vast majority of papers used the mYPAS for diagnosis although there is still some debate about the most appropriate
diagnostic tool. Further studies are needed to assess the factors influencing perioperative anxiety and to evaluate the impact of
perioperative anxiety on the patient experience and recovery.

Background: Depression is the second major cause of disability and is a principal source of disease burden worldwide which is quite common among international students.
Aim: This study explored the depression and its associated factors among international students of a private university in Bangladesh.
Methods: This cross-sectional study was conducted among 149 international students at a private university in Dhaka, Bangladesh using the Center for Epidemiologic Studies Depression (CES-D 10) Scale.
Results: The prevalence of depressive symptoms among international students was 47.7%. Students’ age, marital status, satisfaction with living conditions and problems concerning studies, food, homesickness, finances, accommodation, and health were significantly associated with depression.
Conclusion: This study concluded that there is an unmet need for psychological support for international students studying in Bangladesh. Appropriate support services should be directed to them to help and to overcome the challenges they face.

Objective: To investigate whether patients with a visible skin disorder (acne) and non-visible disorder (psoriasis/eczema) present body image changes after dermatological treatment. Secondly, to examine whether the existence of body dysmorphic disorder (BDD) influences patients’ desire to receive more medical treatments after initial treatment.
Materials and methods: A battery of questionnaires assessing body image, BDD and satisfaction with the medical outcome was shared with patients before treatment and with a six-month follow-up (after each patient completed their treatment). The sample included 54 patients with visible facial acne, 54 patients with non-visible psoriasis/eczema, and 54 participants without a dermatological disorder (control group). All patients were treated by dermatologists and were 18-35 years old.
We examined body image and demographic characteristics using Multivariate analysis of covariance (MANCOVA) between all the study groups. Performing MANCOVA analysis we investigated patients’ body image and appearance satisfaction, before and after treatment, compared to the control group. Finally, to examine the role of BDD on patients’ desire to receive more treatments, MANCOVA analysis was performed, with BDD diagnosis as a covariate variable.
Results: At both research phases, both groups of dermatological patients exhibited lower levels of appearance satisfaction, compared to the control group. MANCOVA analysis revealed that after treatment, acne patients diagnosed with BDD presented even lower levels of facial and overall satisfaction. Moreover, acne patients showed a higher desire for more treatments that improve the skin’s appearance, compared to psoriasis/eczema patients.
Conclusion: Dermatological disorders negatively affect patients’ body image, which does not improve even after dermatological treatment completion. Patients with acne seem to be more dissatisfied with their facial and overall appearance, while their dissatisfaction is projected on other body parts. Lastly, the coexistence of BDD symptomatology increases patients’ desire to seek further aesthetic and cosmetic treatments, to further improve the skin’s appearance after treatment.

Mixed states have long been recognised as being important in psychiatry. In this paper, we review the history of these concepts and recent developments in the field.

Objective:  The COVID-19 pandemic has affected the mental health and well-being of millions of people across the globe. This study aimed to assess the severity of depression, anxiety and stress level among persons who sought teleconsultation during the lockdown period in Kashmir, India.
Materials and methods: This cross-sectional study was carried out from 21 March to 31 May 2020 in Kashmir, India. A call line was set up for people with mental health concerns and participants who signed up for the service were included in the study. The mental health services were provided by a team via teleconsultation. The Depression, Anxiety and Stress Scale (DASS-21) questionnaire was used to assess the severity of distress.
Results: A total of 293 people were interviewed during the teleconsultation service. The mean age was 37.10 (± 10.54) years, the majority had moderate depression, 125 (42.7%), followed by extreme severe depression, 95 (32.4%). The mean depression score on the DASS-21 scale was 13.52 ± 4.13. A total of 276 (94.2%) patients had severe anxiety following lockdown with a mean anxiety score of 14.04 ± 9.23. Also, 96 (32.8%) of people had mild stress with a mean stress score of 12.82 ± 7.32.
Conclusion: The severity of depression, anxiety and stress was high in our study population highlighting the need to provide critical mental health services. Teleconsultations could be an alternative approach to provide such services in areas with public health emergencies and where medical infrastructure is limited.

Objective: This paper describes the protocol of a process evaluation of a cluster randomised controlled trial designed to evaluate the effectiveness, cost-effectiveness and implementation of a digital mental health intervention, called DIALOG+, in five low- and middle-income countries in Southeast Europe (Bosnia and Herzegovina, Kosovo1, Montenegro, North Macedonia and Serbia). The objectives of the process evaluation are: a) to explore attributes of context that might impact on the implementation of the DIALOG+ intervention; b) to assess intervention fidelity and c) to explore patients’ and clinicians’ retrospective (i.e. experienced) acceptability of the intervention.
Materials and methods: This is a mixed-method process evaluation nested within the cluster randomised controlled trial. We adopted the guidance on process evaluations of complex interventions published by the United Kingdom Medical Research Council. Data collected during and after the trial, but prior to awareness of trial outcomes, include transcripts, questionnaire responses, routinely collected monitoring data and audio-recordings of intervention and control sessions. Data analysis is descriptive and involves triangulation methods to compare findings across countries, stakeholder groups (healthcare provider, patient) and data type (qualitative, quantitative).
Results: This work is part of a larger study entitled ‘Implementation of an effective and cost-effective intervention for patients with psychotic disorders in low and middle-income countries in Southeast Europe’ (IMPULSE). The study is funded by the European Union’s Horizon 2020 research and innovation programme. The IMPULSE trial recruited 81 clinicians and 458 patients. The clinician clusters were randomised to the intervention (six sessions of DIALOG+ over 12 months) or treatment-as-usual arm. Process data collection began in parallel with the trial, starting in April 2019. Data collection and analysis will be completed before the main trial findings are known. Process evaluation findings will be used to interpret the trial results including assessing the effect of context on outcomes.
Conclusion: This process evaluation will explore the context, intervention fidelity and acceptability to contextualise the trial results, help in optimising sustainability of the intervention and inform its future dissemination. The methods described here may also inform the development and implementation of other complex psychosocial interventions in low-resource settings.

Background: There are limited resources for improving mental health care across Europe, especially in Low-and-Middle- Income Countries (LMICs) in South-eastern Europe with fewer specialist staff and less funding. Scaling up psychosocial interventions that utilise available time and resources more effectively could improve care for people with psychosis in these settings. One intervention is DIALOG+, delivered via an app on a tablet computer: patients identify life areas to improve and clinicians use a solution-focussed process to help improve these areas. This intervention was piloted across mental healthcare systems in European LMICs, and focus groups were conducted to explore whether such interventions could use available resources effectively to improve care for psychosis in these settings.
Methods: Eleven focus groups were conducted with clinicians and patients with psychosis who used the intervention over three months during the pilot study, in Bosnia and Herzegovina, Kosovo United Nations Resolution, Montenegro, North Macedonia and Serbia. The Theoretical Domains Framework (TDF), which describes factors affecting engagement with healthcare interventions, structured topic guides and guided analysis. Codes from the data were mapped onto the TDF, analysed to identify barriers and facilitators, translated into English and checked for inter-rater reliability.
Results: 25 clinicians and 23 patients participated in focus groups. Clinicians’ barriers included limited time for sessions and difficulties working with acutely psychotic patients. Patients’ barriers were burden of greater concentration when engaging with DIALOG+ and feeling tense or disturbed during the sessions. Facilitators included motivation to use DIALOG+, positive opinions shared by others, perceived benefits for practice and improving clinician-patient conversations, relationships and care.
Conclusions: Barriers to using psychosocial interventions could be overcome even if resources cannot be increased. Despite limited time and other barriers to using DIALOG+, perceived benefits to practice and clinician-patient relationships suggest that psychosocial interventions can use available resources effectively to improve care for psychosis.

Objective:  Since 2000, over 350,000 US military personnel have been diagnosed with a traumatic brain injury (TBI) (VA, 2010). Whilst epidemiological studies report up to a fourfold increased risk for dementia associated with brain injury amongst veterans there is limited controlled research into the long-term neuropsychological burden of injury.
Main aim:  The study aimed to determine whether Australian Vietnam war veterans with service-related TBI were more likely to exhibit cognitive deficits, 30-50 years after injury when compared to healthy veteran controls.
Materials and methods: 69 male veterans 60-85 years old, underwent psychiatric and neuropsychological assessment; 40 with a TBI (mean age = 68.0 ± 2.5) and 29 without (mean age = 70.1 ± 5.3). The TBI cohort included 15 mild, 16 moderate and nine severe TBI.
Results: After adjustment for identified covariates, veterans with moderate-to-severe TBI performed significantly worse than controls on composite measures of memory and learning (M = -0.55 ± 0.69, t(67) = 2.86, p=0.006, d=0.70) and attention and processing speed (M = -0.71 ± 1.08, t(52) = 2.53, p=0.014, d=0.69). There were no differences in cognitive performance between veterans with mild TBI (mTBI) and controls.
Conclusion: Results from this study suggest that amongst ageing veterans, a moderate-to-severe TBI sustained during early adulthood is associated with later-life cognitive deficits in memory and learning, attention and processing speed.

Objective:  Traumatic Brain Injury (TBI) and Post-Traumatic Stress Disorder (PTSD) are common in military veterans and have been associated with an increased risk of dementia. The mechanisms contributing to this relationship are poorly understood.
Main aim: This study investigated the effect of TBI and PTSD on white matter (WM) integrity, hippocampal and cortical volume within a cohort of Vietnam veterans.
Materials and methods: 87 male veterans in total. There were 31 with TBI (aged 69.0 ± 2.5 years), 35 with PTSD (aged 69.5 ± 2.6 years) and 21 controls (aged 70.1 ± 4.9 years) underwent 3Tesla Magnetic Resonance Imaging (MRI). The TBI cohort included 12 mild, 13 moderate and six severe injuries. WM integrity was assessed using tract-based spatial statistics and region-specific analyses of fractional anisotropy (FA) images. Automated processing of T1-weighted magnetisation-prepared rapid gradient-echo (MPRAGE) images resulted in hippocampal volumes and whole-brain cortical thickness estimation. Analyses were adjusted for IQ, Body Mass Index (BMI) and psychiatric comorbidities.
Results: The moderate-to-severe TBI group had significantly lower FA than controls in the genu (F(3,36)=8.81, p<0.05, partial η2 = 0.17), and body (F(3,36)=4.39, p <0.05, partial η2=0.14) of the corpus callosum, as well as in global WM (F(3,36)=5.35, p <0.05, partial η2=0.13). The PTSD FA values did not differ from controls and neither the TBI nor PTSD group differed significantly from controls in hippocampal volume nor cortical thickness in Alzheimer’s disease vulnerable regions.
Conclusion: These findings suggest that the widely reported loss of WM integrity observed after moderate to severe TBI persists throughout life but is not associated with hippocampal or grey matter atrophy after four decades. No PTSD-related structural or FA change was observed.

In March 2020, the World Health Organization (WHO) declared the COVID-19 outbreak a pandemic. The Section on Suicidology and Suicide Prevention of the European Psychiatric Association (EPA) wants to raise awareness about the potential increase in mental health disorders and suicides as a result of the socio-economic impact of the COVID-19 pandemic, and of the necessary restrictive measures adopted worldwide to contain its spread. Even if fear, worries and symptoms of anxiety, depression and stress can be considered a natural response to this global crisis, some individuals are overexposed to its potential negative effects, such as healthcare workers, COVID-19 and psychiatric patients, prisoners, members of the LGBTQ+ community, migrants (including migrant workers), ethnic minorities and asylum seekers and internally displaced populations. Nevertheless, social support, resilience, a supportive work environment and other protective factors may buffer the impact of this crisis on mental health. These unprecedented times are calling for unprecedented efforts. Evidence-based and coordinated actions to prevent the risk of increased mental health disorders and suicide are needed. However, most of the data about COVID-19 impact on mental health comes from online surveys using non-probability and convenience sample in which females are often over-represented. For this reason the quality of future research should be also improved.