Volume 4, Issue 1, Winter and Spring 2021
2021, Volume 4, Issue 1, Pages 1-3
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.
Increased risk for mental disorders and suicide during the COVID-19 pandemic. Position statement of the Section on Suicidology and Suicide Prevention of the European Psychiatric Association.
2021, Volume 4, Issue 1, Pages 4-19
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.
Protocol for a process evaluation of a cluster randomised controlled trial to improve psychosocial treatment of patients with psychotic spectrum disorders: the IMPULSE trial
2021, Volume 4, Issue 1, Pages 20-30
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.
Implementing a mental health intervention in low-and-middle-income countries in Europe: is it all about resources?
2021, Volume 4, Issue 1, Pages 31-54
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.
Depression and associated factors among international students in a private University of Bangladesh
2021, Volume 4, Issue 1, Pages 55-61
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.
Severity of depression, anxiety and stress among the people of Kashmir, India during COVID-19: An observation from tele psychiatric services
2021, Volume 4, Issue 1, Pages 62-67
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.
2021, Volume 4, Issue 1, Pages 68-79
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.
2021, Volume 4, Issue 1, Pages 80-94
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.
The critical role of body dysmorphic disorder in dermatological patients’ body image: patients’ desire to seek even more medical treatments increases after dermatological treatment
2021, Volume 4, Issue 1, Pages 95-108
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.
2021, Volume 4, Issue 1, Pages 109-122
Background: An adequate number of empirical studies is necessary to formulate a national suicide prevention programme.
Aims: To assess the extent of empirical studies on suicide in a decade (2011-2020) in Bangladesh.
Materials and methods: A literature search was conducted to identify the articles available in PubMed, PubMed Central, Scopus, Google Scholar, and BanglaJOL using the search term “suicide in Bangladesh”, “self-harm in Bangladesh”, “poisoning in Bangladesh”, “suicidal behaviour in Bangladesh”. We included all the original articles in full-length format that were published in the English language, accessible in the full texts, published between 2011 and 2020, and assessing suicidal behaviour in Bangladesh. A total of 44 empirical studies were included in this review.
Results: Among the 44 studies, 6.8% were qualitative studies, 34.1% applied interview, 31.8% analysed the secondary data. All the studies followed a cross-sectional design, nine studies assessed youth suicidality, and only one study assessed the suicidality among the elderly. Studies of the earlier half of the decade explored epidemiological aspects, whereas studies in the last five years assessed the newer topics such as quality of media reporting, psychological autopsy study, perspectives after nonfatal attempt, sociological perspectives, ontological perspectives, masculinity, and suicide, and financial loss due to suicide. About 41% of the papers had a collaboration with the authors of other countries, and about 18.2% of the papers were externally funded either partially or fully.
Conclusion: Although newer studies are coming out, suicide is an under-studied public health problem as no nationwide, longitudinal and interventional study has been identified during a decade (2011-2020) in Bangladesh. The proper attention of all the stakeholders is warranted to improve the scenario.