Suicidality in patients with bipolar depression:Findings from a lower middle-income country

AIMS: Among low- and middle-income countries (LMICs), bipolar disorder is recognized as one of the leading causes of disease burden for adults and is associated with marked suicide risk. There are limited data on suicidal ideation in bipolar disorder from LMICs. This study presents cross-sectional data on the prevalence of suicidality and associated patient characteristics among patients with bipolar depression in Pakistan, a lower-middle income country and the fifth most populous country in the world. METHOD: Participants were recruited through outpatient psychiatric clinics in between 2016–2019 in Karachi, Lahore, Hyderabad and Rawalpindi between 2016–2019. Participants were aged 18 to 65 years with a known diagnosis of bipolar disorder and currently in a depressive episode. Suicidality was assessed using the suicide item of the 17-item Hamilton Depression Rating Scale (HAM-D) and levels of severity were categorized as absent, mild/moderate, or severe. Biometric data and biomarkers were obtained. Descriptive statistics were used to describe prevalence and proportional odds regression models were applied to establish correlates to suicidal ideation. RESULT: Among the 266 participants, 67% indicated suicidality of any level and 16% endorsed severe suicidality. Lower body mass index (BMI) (OR = 0.93, 95% CI = 0.88–0.98), higher HAM-D score (OR = 1.29, 95% CI = 1.16–1.43), lower C-reactive protein (CRP) level (OR = 0.53, 95% CI = 0.40–0.70), and increased number of inpatient hospitalizations (OR = 1.16, 95% CI = 1.03–1.31) were identified as significant predictors of suicidality in the fully adjusted regression model. No patient demographic data, including age, gender, marital status, socioeconomic status, and years of education were associated with severity of suicidality. CONCLUSION: There exists a high prevalence of suicidal ideation among patients with bipolar depression in Pakistan. Our findings add to the limited literature on suicidality in bipolar disorder in the LMIC context and suggest roles of biological variables such as BMI and CRP level in predicting suicidal ideation and potentially suicidal behaviours in bipolar depression. More studies are needed to see whether such findings can be replicated in other similar LMIC settings, and to explore potential physiological pathways linking BMI, inflammatory biomarkers and suicidality in bipolar disorder

Pilot randomised controlled trial of culturally adapted cognitive behavior therapy for psychosis (CaCBTp) in Pakistan

Abstract Background Evidence for efficacy of cognitive-behavioural therapy (CBT) in treatment of schizophrenia is growing. CBT is effective and cost efficient in treating positive and negative symptoms. To effectively meet the needs of diverse cultural groups, CBT needs to be adapted to the linguistic, cultural and socioeconomic context. We aimed to assess the feasibility, efficacy and acceptability of a culturally adapted CBT for treatment of psychosis (CaCBTp) in a low-income country. Methods Rater-blind, randomised, controlled trial of the use of standard duration CBT in patients with psychosis from a low-income country. Participants with a ICD-10 diagnosis of psychosis were assessed using Positive and Negative Syndrome Scale for Schizophrenia (PANSS), Psychotic Symptom Rating Scales (PSYRATS), and the Schedule for Assessment of Insight (SAI) (baseline, 3 months and 6 months). They were randomized into the intervention group (n = 18) and Treatment As Usual (TAU) group (n = 18). The intervention group received 12 weekly sessions of CaCBTp. Results The CaCBTp group had significantly lower scores on PANSS Positive (p = 0.02), PANSS Negative (p = 0.045), PANSS General Psychopathology (p = 0.008) and Total PANSS (p = 0.05) when compared to TAU at three months. They also had low scores on Delusion Severity Total (p = 0.02) and Hallucination Severity Total (p = 0.04) of PSYRATS, as well as higher scores on SAI (p = 0.01) at the same time point. At six months only the improvement in PANSS positive scores (p = 0.045) met statistical significance.. Conclusions It is feasible to offer CaCBTp as an adjunct to TAU in patients with psychosis, presenting to services in a lower middle-income country. Trial registration Clinicaltrials.gov identifier NCT02202694 (Retrospectively registered)

Clinicians', patients' and carers' perspectives on borderline personality disorder in Pakistan: A mixed methods study protocol

Borderline Personality Disorder (BPD) is a condition characterised by significant social and occupational impairment and high rates of suicide. In high income countries, mental health professionals carry negative attitudes towards patients with BPD, find it difficult to work with patients with BPD, and even avoid seeing these patients. Negative attitudes and stigma can cause patients to fear mistreatment by health care providers and create additional barriers to care. Patients' self-stigma and illness understanding BPD also affects treatment engagement and outcomes; better knowledge about mental illness predicts intentions to seek care. The perspectives of mental health clinicians and patients on BPD have not been researched in the Pakistani setting and likely differ from other settings due to economic, cultural, and health care system differences. Our study aims to understand the attitudes of mental health clinicians towards patients with BPD in Pakistan using a self-report survey. We also aim to explore explanatory models of illness in individuals with BPD and their family members/carers using a Short Explanatory Model Interview (SEMI). The results of this study are important as we know attitudes and illness understanding greatly impact care. Results of this study will help guide BPD-specific training for mental health clinicians who care for patients with BPD and help inform approaches to interventions for patients with BPD in Pakistan

Controlled interventions to improve suicide prevention in educational settings: a systematic review and network meta-analysis

Background: Suicidal thoughts and behaviors (STBs) in young people is a major public health problem, which is on the rise globally. Aims: We applied the first network meta-analyses to examine the effectiveness of existing intervention types and contents to reduce STBs and improve suicide prevention competencies in educational settings. Method: We searched Medline, PsycInfo, and CENTRAL until April 2021. Quantitative studies focused on young people aged between 12 and 25 years which evaluated interventions at educational settings and contained comparator groups were included. Results: Overall, we identified 49 studies comprising 42,039 participants. Regarding the type of intervention, universal interventions (OR = 1.85, 95% confidence interval [CI] [1.43–2.38]) were associated with almost two-fold reductions in the odds of STBs. Selective (standardized mean difference [SMD] = 0.51, 95% CI [0.32–0.70]) and universal interventions (SMD = 0.40, 0.26–0.54) were moderately effective in increasing suicide prevention competencies. Regarding the content of the intervention, education/awareness programs (OR = 1.59, 95% CI [1.23–2.04]) and psychotherapy programs (OR = 2.22, [1.25–3.33]) were associated with 1.5- and two-fold reductions in the odds of STBs. Gatekeeper universal interventions (SMD = 1.04, 95% CI [0.73–1.34]) and gatekeeper selective interventions (SMD = 0.52, [0.26–0.77]) were strong-to-moderately more effective in increasing suicide prevention competencies when compared to no-treatment. Education/awareness interventions were also modestly effective (SMD = 0.28, 95% CI [0.12–0.44]). The quality of 81% of the included studies was low. Conclusions: Important policy actions should be taken with a focus on offering universal mental health/suicide awareness training programs and/or selective treatments to reduce STBs and improve suicide prevention competencies in educational settings