Psychometric properties of the AUDIT among men in Goa, India.

AIMS: The Alcohol Use Disorders Identification Test (AUDIT) is a 10-item screening questionnaire used to detect alcohol use disorders. The AUDIT has been validated in only two studies in India and although it has been previously used in Goa, India, it has yet to be validated in that setting. In this paper, we aim to report data on the validity of the AUDIT for the screening of AUDs among men in Goa, India. METHODS: Concurrent and convergent validity of the AUDIT were assessed against the Mini International Neuropsychiatric Interview (MINI) and World Health Organisation Disability Assessment Scale (WHODAS) for alcohol abuse, alcohol dependence, and functional status respectively through the secondary analysis of data from a community cohort of men from Goa, India. RESULTS: The AUDIT showed high internal reliability and acceptable criterion validity with adequate psychometric properties for the detection of alcohol abuse and dependence. However, all of the optimal cut-off points from ROC analyses were lower than the WHO recommended for identification of risk of all AUDs, with a score of 6-12 detecting alcohol abuse and 13 and higher alcohol dependence. CONCLUSIONS: In order to optimize the utility of the AUDIT, a lowered cut-off point for alcohol abuse and dependence is recommended for Goa, India. Further validation studies for the AUDIT should be conducted for continued validation of the tool in other parts of India

The psychometric properties of GHQ for detecting common mental disorder among community dwelling men in Goa, India.

BACKGROUND: There have not been many attempts to validate screening measures for common mental disorders (CMD) in low- and middle-income countries. The aim of this study was to examine the criterion validity of the General Health Questionnaire 12 (GHQ-12) in a community-based study from Goa, India. METHOD: Concurrent and convergent validity of the GHQ-12 were assessed against the Mini International Neuropsychiatric Interview (MINI) and World Health Organization Disability Assessment Scale (WHODAS) for CMD and functional status through the secondary analysis of a community cohort of men from Goa, India. Criterion validity of the GHQ-12 was determined using ROC analyses with the MINI case criterion as the gold standard. Concurrent validity was assessed against the gold standard of WHODAS functional disability and number of disability days. RESULTS: In a sample of men (n=773), the GHQ-12 showed high internal reliability (Cronbach's alpha of 0.82) and acceptable criterion validity (Area under the receiver operating characteristic curve being 0.71). It had adequate psychometric properties for the detection of CMD (sensitivity of 68.75%; specificity of 73.14%) with the optimal cut-off score for identification of CMD being 2. CONCLUSION: In order to optimize the usefulness and validity of the GHQ-12, a low cut-off point for CMD may be beneficial in Goa, India. Further validation studies for the GHQ-12 should be conducted for continued validation of the test for use in the community

PREMIUM twelve-month follow-up trial: Clinical Outcomes and Cost-effectiveness dataset from the Healthy Activity Program (HAP) RCT

The Program for Effective Mental Health Interventions in Under-Resourced Health Systems (PREMIUM) sought to develop and assess scalable psychological treatments that are culturally appropriate, affordable, and feasible for delivery by non-specialist health workers and apply these treatments to the two leading mental health disorders: moderately severe to severe depression (the Healthy Activity Program [HAP]) and harmful drinking (Counselling for Alcohol Problems [CAP]). This data collection contains records of adult male/female Primary Health Centres (PHC) attenders (one patient per row) recruited in the trials site between October 28th 2013 and July 30th 2015, and followed-up for outcome assessments until September 30th 2016. It encompasses enrolment, treatment process (including therapy quality), cost-effectiveness, and clinical/other outcome data. Only variables relevant for the analysis of our twelve-month follow-up are presented. The HAP dataset is made available on request, in accordance with ethical constraints outlined in the participant consent agreement. To obtain access, interested parties must complete a data request form or email [email protected] outlining the purpose for which they intend to use the dataset and agree to sign a licence agreement confirming that they will protect participant confidentiality

Perinatal Depression in Rural Ghana: Burden, Determinants, Consequences, and Impact of a Community-Based Intervention.

The relative lack of research in mental health in low and middle income countries is symptomatic of the 10/90 gap in general health research where only 10% of the world’s expenditure on health research is dedicated to the poorest 90% of the world’s population. Globally there has been modest declines in both maternal and child deaths but there are still wide disparities between developed and developing countries; as the total number of under 5 deaths has declined, from 11.6 million in 1990 to 7.2 million in 2011, the proportion of deaths occurring in sub-Saharan Africa has increased from 33% in 1990 to 49% in 2011, and the region also bears the biggest burden (>50%) of maternal deaths. Innovations to reducing this burden are urgently needed in parallel with intensified efforts to increase coverage of proven effective maternal and child health interventions. One such innovation might be to include a focus on eliciting contextual determinants, and preventing and/or treating perinatal depression that is depression occurring during pregnancy or after birth, since there is some evidence suggesting that this is associated with adverse effects on infant health and development, and maternal health. This thesis is designed to add to this sparse evidence base by providing data on the burden of antenatal and postnatal depression in rural Ghana, examining determinants of this burden, investigating the links between perinatal depression and maternal and child health outcomes, and evaluating whether a home-visits intervention had reduced this burden. The research was undertaken within seven contiguous districts of the Brong Ahafo region of Ghana between January 2008 and July 2009. All women of reproductive age in these districts were part of a surveillance system supporting two randomised controlled trials that involved 4-weekly visits by resident fieldworkers who collected data on socio-demographics, obstetric histories, pregnancies, births, deaths and infant and maternal health. The research for this PhD involved training the surveillance field workers to also administer the depression module of the Patient Health Questionnaire screening tool (PHQ-9) to pregnant women and recently delivered mothers between 4-12 weeks after birth. 21135 pregnant women and 18356 recently delivered women were screened for depression, 13929 of whom were screened at both time points. The prevalence of postnatal depression (PND) was 3.8% (95% CI 3.5%, 4.1%), comprising 0.1% (95% CI: 0.08%-0.1%) who met criteria for major depression and 3.7% (95% CI: 3.4%-3.9%) for minor depression. The prevalence of antenatal depression (AND) was much higher 9.9% (95% CI: 9.5%-10.3%); 12.5% of these cases persisted into the postnatal period and accounted for 34.4% of postnatal cases. The following determinants were identified for antenatal depression: maternal age 30 years or older, never married, lower wealth status, non-Catholic religion, non-indigenous ethnicity, unplanned pregnancy, and previous pregnancy loss. And the following were identified for postnatal depression: never married, non-indigenous ethnicity, AND, season of delivery, peripartum/postpartum complications, newborn ill-health, still birth or neonatal death. Determinants were similar for ‘new’ cases of postnatal depression and for cases where depression was also detected antenatally. AND was found to be associated with the following consequences: prolonged labour, postpartum complications, peripartum complications, CS/instrumental delivery, severe newborn illness, and bed net non-use during pregnancy. PND was associated with increased risk of infant mortality up to six months (rate ratio [RR], 2·83 (1·56-5·16) and 12 months (RR, 1·79 (1·04-3·09) of age. Postnatal depression was also associated with increased risk of infant morbidity. Home-visits by community volunteers aimed at preventing neonatal deaths had no impact on attenuating prevalence of postnatal depression (relative risk [RR] 0.99 (95% CI 0.65, 1.50; p=0.96). This is the first large cohort study in SSA to provide evidence of determinants and consequences of perinatal depression, rather than studying the more general common mental disorder which include depression. The conclusions reached in this PhD are:1) Most risk factors of postnatal depression relate to adverse birth outcomes of the mother and/or baby, whereas those of antenatal depression are sociodemographic and pregnancy-specific, 2) Both antenatal and postnatal depression may have deleterious effects on the health of the mother and/or on child health and survival, 3) A case for clinical interventions for depression is established both during pregnancy and after birth, 4) Though often self-limiting, tackling antenatal depression could prevent up to a third of the burden of postnatal depression, 5) The timely implementation of such interventions using existing primary care structures may provide an important adjunct to improving maternal health and child health and survival efforts

Effect of the Newhints home-visits intervention on neonatal mortality rate and care practices in Ghana: a cluster randomised controlled trial.

BACKGROUND: In 2009, on the basis of promising evidence from trials in south Asia, WHO and UNICEF issued a joint statement about home visits as a strategy to improve newborn survival. In the Newhints trial, we aimed to test this home-visits strategy in sub-Saharan Africa by assessing the effect on all-cause neonatal mortality rate (NMR) and essential newborn-care practices. METHODS: The Newhints cluster randomised trial was undertaken in 98 zones in seven districts in the Brong Ahafo Region, Ghana. 49 zones were randomly assigned to the Newhints intervention and 49 to the control intervention by use of restricted randomisation with stratification to ensure comparability between interventions. Community-based surveillance volunteers (CBSVs) in Newhints zones were trained to identify pregnant women in their community and to make two home visits during pregnancy and three in the first week of life to promote essential newborn-care practices, weigh and assess babies for danger signs, and refer as necessary. Primary outcomes were NMR and coverage of key essential newborn-care practices. Analyses were by intention to treat. This study is registered with ClinicalTrials.gov, number NCT00623337. FINDINGS: 16,168 (99%) of 16,329 deliveries between November, 2008, and December, 2009, were livebirths; the status at 1 month was known for 15,619 (97%) livebirths. 482 neonatal deaths were recorded. Coverage data were available from 6029 women in Newhints zones; of these 4358 (72%) reported having CBSV visits during pregnancy and 3815 (63%) reported having postnatal visits. This coverage increased substantially from June, 2009, after the introduction of new implementation strategies and reached almost 90% for pregnancy visits by the end of the trial and 75% for postnatal visits. The Newhints intervention significantly increased coverage of key essential newborn-care behaviours, except for four or more antenatal-care visits (5975 [76%] of 7859 vs 5988 [74%] of 8121, respectively; relative risk 1·02, 95% CI 0·96-1·09; p=0·52) and baby delivered in a facility (5373 [68%] vs 5539 [68%], respectively; 0·97, 0·81-1·14; p=0·69). The largest increase was for care-seeking, with 102 (77%) of 132 sick babies in Newhints zones taken to a hospital or clinic compared with 77 (55%) of 139 in control zones (1·43, 1·17-1·76; p=0·001). Increases were also noted in bednet use during pregnancy (5398 [69%] of 7859 vs 5135 [63%] of 8121, respectively; 1·12, 1·03-1·21; p=0·005), money saved for delivery or emergency (5730 [86%] of 6681 vs 5525 [80%] of 6941, respectively; 1·09, 1·05-1·12; p<0·0001), transport arranged in advance for facility (2496 [37%] vs 2061 [30%], respectively; 1·30, 1·12-1·49; p=0·0004), birth assistant for home delivery washed hands with soap (1853 [93%] of 1992 vs 1817 [87%] of 2091, respectively; 1·05, 1·02-1·09; p=0·001), initiation of breastfeeding in less than 1 h of birth (3743 [49%] of 7673 vs 3280 [41%] of 7921, respectively; 1·22, 1·07-1·40; p=0·004), skin to skin contact (3355 [44%] vs 1931 [24%], respectively; 2·30, 1·85-2·87; p=0·0002), first bath delayed for longer than 6 h (3131 [41%] vs 2269 [29%], respectively; 1·65, 1·27-2·13; p<0·0001), exclusive breastfeeding for 26-32 days (1217 [86%] of 1414 vs 1091 [80%] of 1371; 1·10, 1·04-1·16; p=0·001), and baby sleeping under bednet for 8-56 days (4548 [79%] of 5756 vs 4291 [73%] of 5846; 1·09, 1·03-1·15; p=0·002). There were 230 neonatal deaths in the Newhints zones compared with 252 in the control zones. The overall NMRs per 1000 livebirths were 29·8 and 31·9, respectively (0·92, 0·75-1·12; p=0·405). INTERPRETATION: The reduction in NMR with Newhints is consistent with the reductions achieved in three trials undertaken in programme settings in south Asia. Because there is no suggestion of any heterogeneity (p=0·850) between these trials and Newhints, the meta-analysis summary estimate of a reduction of 12% (95% CI 5-18) provides the best evidence for the likely effect of the home-visits strategy delivered within programmes in sub-Saharan Africa and in south Asia. Improvements in the quality of delivery and neonatal care in health facilities and development of innovative, effective strategies to increase coverage of home visits on the day of birth could lead to the achievement of more substantial reductions. FUNDING: WHO, Bill & Melinda Gates Foundation, and UK Department for International Development

Measuring depression severity in global mental health: comparing the PHQ-9 and the BDI-II

Grant information: This research was funded by a Wellcome Trust Senior Research Fellowship grant to VP [091834]. BW is supported through an Intermediate Research Fellowship from the Wellcome Trust/India Alliance [502680]. The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript.Peer reviewedPublisher PD

Association between probable postnatal depression and increased infant mortality and morbidity: findings from the DON population-based cohort study in rural Ghana.

OBJECTIVES: To assess the impact of probable depression in the immediate postnatal period on subsequent infant mortality and morbidity. DESIGN: Cohort study nested within 4 weekly surveillance of all women of reproductive age to identify pregnancies and collect data on births and deaths. SETTING: Rural/periurban communities within the Kintampo Health Research Centre study area of the Brong-Ahafo Region of Ghana. PARTICIPANTS: 16,560 mothers who had a live singleton birth reported between 24 March 2008 and 11 July 2009, who were screened for probable postnatal depression (pPND) between 4 and 12 weeks post partum (some of whom had also had depression assessed at pregnancy), and whose infants survived to this point. PRIMARY/SECONDARY OUTCOME MEASURES: All-cause early infant mortality expressed per 1000 infant-months of follow-up from the time of postnatal assessment to 6 months of age. The secondary outcomes were (1) all-cause infant mortality from the time of postnatal assessment to 12 months of age and (2) reported infant morbidity from the time of the postnatal assessment to 12 months of age. RESULTS: 130 infant deaths were recorded and singletons were followed for 67,457.4 infant-months from the time of their mothers' postnatal depression assessment. pPND was associated with an almost threefold increased risk of mortality up to 6 months (adjusted rate ratio (RR), 2.86 (1.58 to 5.19); p=0.001). The RR up to 12 months was 1.88 (1.09 to 3.24; p=0.023). pPND was also associated with increased risk of infant morbidity. CONCLUSIONS: There is new evidence for the association between maternal pPND and infant mortality in low-income and middle-income countries. Implementation of the WHO's Mental Health Gap Action Programme (mhGAP) to scale up packages of care integrated with maternal health is encouraged as an important adjunct to child survival efforts

Association between probable postnatal depression and increased infant mortality and morbidity: findings from the DON population-based cohort study in rural Ghana.

OBJECTIVES: To assess the impact of probable depression in the immediate postnatal period on subsequent infant mortality and morbidity. DESIGN: Cohort study nested within 4 weekly surveillance of all women of reproductive age to identify pregnancies and collect data on births and deaths. SETTING: Rural/periurban communities within the Kintampo Health Research Centre study area of the Brong-Ahafo Region of Ghana. PARTICIPANTS: 16,560 mothers who had a live singleton birth reported between 24 March 2008 and 11 July 2009, who were screened for probable postnatal depression (pPND) between 4 and 12 weeks post partum (some of whom had also had depression assessed at pregnancy), and whose infants survived to this point. PRIMARY/SECONDARY OUTCOME MEASURES: All-cause early infant mortality expressed per 1000 infant-months of follow-up from the time of postnatal assessment to 6 months of age. The secondary outcomes were (1) all-cause infant mortality from the time of postnatal assessment to 12 months of age and (2) reported infant morbidity from the time of the postnatal assessment to 12 months of age. RESULTS: 130 infant deaths were recorded and singletons were followed for 67,457.4 infant-months from the time of their mothers' postnatal depression assessment. pPND was associated with an almost threefold increased risk of mortality up to 6 months (adjusted rate ratio (RR), 2.86 (1.58 to 5.19); p=0.001). The RR up to 12 months was 1.88 (1.09 to 3.24; p=0.023). pPND was also associated with increased risk of infant morbidity. CONCLUSIONS: There is new evidence for the association between maternal pPND and infant mortality in low-income and middle-income countries. Implementation of the WHO's Mental Health Gap Action Programme (mhGAP) to scale up packages of care integrated with maternal health is encouraged as an important adjunct to child survival efforts

The effectiveness and cost-effectiveness of the peer-delivered Thinking Healthy Programme for perinatal depression in Pakistan and India: the SHARE study protocol for randomised controlled trials.

BACKGROUND: Rates of perinatal depression (antenatal and postnatal depression) in South Asia are among the highest in the world. The delivery of effective psychological treatments for perinatal depression through existing health systems is a challenge due to a lack of human resources. This paper reports on a trial protocol that aims to evaluate the effectiveness and cost-effectiveness of the Thinking Healthy Programme delivered by peers (Thinking Healthy Programme Peer-delivered; THPP), for women with moderate to severe perinatal depression in rural and urban settings in Pakistan and India. METHODS/DESIGN: THPP is evaluated with two randomised controlled trials: a cluster trial in Rawalpindi, Pakistan, and an individually randomised trial in Goa, India. Trial participants are pregnant women who are registered with the lady health workers in the study area in Pakistan and pregnant women attending outpatient antenatal clinics in India. They will be screened using the patient health questionnaire-9 (PHQ-9) for depression symptoms and will be eligible if their PHQ-9 is equal to or greater than 10 (PHQ-9 ≥ 10). The sample size will be 560 and 280 women in Pakistan and India, respectively. Women in the intervention arm (THPP) will be offered ten individual and four group sessions (Pakistan) or 6-14 individual sessions (India) delivered by a peer (defined as a mother from the same community who is trained and supervised in delivering the intervention). Women in the control arm (enhanced usual care) will receive health care as usual, enhanced by providing the gynaecologist or primary-health facilities with adapted WHO mhGAP guidelines for depression treatment, and providing the woman with her diagnosis and information on how to seek help for herself. The primary outcomes are remission and severity of depression symptoms at the 6-month postnatal follow-up. Secondary outcomes include remission and severity of depression symptoms at the 3-month postnatal follow-up, functional disability, perceived social support, breastfeeding rates, infant height and weight, and costs of health care at the 3- and 6-month postnatal follow-ups. The primary analysis will be intention-to-treat. DISCUSSION: The trials have the potential to strengthen the evidence on the effectiveness and cost-effectiveness of an evidence-based psychological treatment recommended by the World Health Organisation and delivered by peers for perinatal depression. The trials have the unique opportunity to overcome the shortage of human resources in global mental health and may advance our understanding about the use of peers who work in partnership with the existing health systems in low-resource settings. TRIAL REGISTRATION: Pakistan Trial: ClinicalTrials.gov Identifier: NCT02111915 (9 April 2014) India Trial: ClinicalTrials.gov Identifier: NCT02104232 (1 April 2014)