The future of psychiatry in low- and middle-income countries

The great shortage, and inequitable distribution, of psychiatrists in low- and middle-income countries is one of the key reasons for the large treatment gap for people with mental disorders. Psychiatrists need to play a public mental health leadership role in increasing the coverage of mental health care through task shifting of effective interventions to non-specialist health workers. Psychiatrists' new roles should include designing and managing such programmes, building clinical capacity, supervision and quality assurance, providing referral pathways and research.

Mental health research priorities in low- and middle-income countries of Africa, Asia, Latin America and the Caribbean

BACKGROUND

Studies suggest a paucity of and lack of prioritisation in mental health research from low- and middle-income (LAMI) countries.

AIMS

To investigate research priorities in mental health among researchers and other stakeholders in LAMI countries.

METHOD

We used a two-stage design that included identification, through literature searches and snowball technique, of researchers and stakeholders in 114 countries of Africa, Asia, Latin America and the Caribbean; and a mail survey on priorities in research.

RESULTS

The study identified broad agreement between researchers and stakeholders and across regions regarding research priorities. Epidemiology (burden and risk factors), health systems and social science ranked highest for type of research. Depression/anxiety, substance use disorders and psychoses; and children and adolescents, women, and people exposed to violence/trauma were prioritised among the disorders and population groups respectively. Important criteria for prioritising research were burden of disease, social justice, and availability of funds. Stakeholder groups differed in the importance they gave to the personal interest of researchers as a criterion for prioritising research. Researchers' and stakeholders' priorities were consistent with burden of disease estimates, however suicide was underprioritised compared with its burden. Researchers' and stakeholders' priorities were also largely congruent with the researchers' projects.

CONCLUSIONS

The results of this first ever conducted survey of researchers and stakeholders regarding research priorities in mental health suggest that it should be possible to develop consensus at regional and international levels regarding the research agenda that is necessary to support health system objectives in LAMI countries.

Depression in Mongolian women over the first 2 months after childbirth: prevalence and risk factors

BACKGROUND

Social, political and economic changes in Mongolia have followed post-Soviet style government policies and contributed to both increased liberalisation and reduced security in employment and family finances. This is the first study to attempt to assess the prevalence of depression in a population of Mongolian women in the post-partum period and assess risk factors, including financial position, associated with the condition.

METHODS

A total of 1044 women who had delivered healthy babies in Ulaanbaatar between October and December 2002 were screened for depression using the WHO Self Reporting Questionnaire between 5 and 9 weeks post-partum. Further details on the mother, her family and social and economic circumstances were simultaneously collected. Analysis of risk factors for probable depression was undertaken using multiple logistic regression techniques.

RESULTS

The prevalence of depression was 9.1% (95% CLs 7.5%-11.1%). Variables significantly and independently associated with risk of probable maternal depression included economic factors, mother being subject to physical abuse, dissatisfied with the pregnancy, concerned about her baby's behaviour, and her own health problems.

LIMITATIONS

The sample was drawn from a population of mothers all of whom had healthy, full-term babies of normal birth weight. Clinical confirmation of diagnosis was not established.

CONCLUSIONS

Mongolian women with young infants in Ulaanbaatar probably experience depression at rates comparable with other cultures. Factors associated with probable depression were dominated by health, relationships and financial position.

The effect of spousal violence on women's health: findings from the Stree Arogya Shodh in Goa, India

BACKGROUND

Spousal violence has wide-ranging effects on the physical, reproductive, sexual and psychological health of women. There are few longitudinal studies that describe this association in developing countries.

AIM

To test the hypothesis that spousal violence is an independent risk factor for a broad range of adverse health outcomes in women.

SETTING AND DESIGN

A population-based cohort study of women living in the catchment area of a primary health center in north Goa. Two thousand four hundred and ninety-four of 3000 randomly selected women were recruited of whom 1750 married women were included for this paper.

MATERIALS AND METHODS

Each participant was assessed at baseline with a structured interview for the assessment of exposure to spousal violence (verbal, physical, sexual) over two time periods (lifetime; recent in the past three months). The interview collected data on gynecological complaints and the Revised Clinical Interview Schedule was used for the diagnosis of depressive disorder. Laboratory tests for anemia and sexually transmitted infections (STI) were carried out. Longitudinal data was collected after six and 12 months on these outcomes. In addition, baseline measures for nutritional status and menstrual health were also obtained.

STATISTICAL ANALYSIS

Univariate analyses were carried out on the cross-sectional and longitudinal data to assess the association between each type of spousal violence and each health outcome. Multivariate analyses adjusted for age, literacy, household per capita income. Logistic regression was used for all analyses in Stata (Version 10).

RESULTS

Lifetime spousal violence was reported by 290 (16.6%, 95%CI=14.9-18.4) women; recent violence was reported by 230 (13.0%, 95%CI=11.6-14.8). The cross-sectional data showed an association between violence and a range of self-reported gynecological complaints, low Body Mass Index, depressive disorder and attempted suicide. The longitudinal analyses confirmed these associations only for STI and attempted suicide.

CONCLUSION

Spousal violence is specifically associated as an independent risk factor for two adverse women's health outcomes, viz., STI and attempted suicide. Public health and clinical programs targeting these outcomes must specifically address spousal violence.

Self-calibration of a cone-beam micro-CT system

Use of cone-beam computed tomography (CBCT) is becoming more frequent. For proper reconstruction, the geometry of the CBCT systems must be known. While the system can be designed to reduce errors in the geometry, calibration measurements must still be performed and corrections applied. Investigators have proposed techniques using calibration objects for system calibration. In this study, the authors present methods to calibrate a rotary-stage CB micro-CT (CBmicroCT) system using only the images acquired of the object to be reconstructed, i.e., without the use of calibration objects. Projection images are acquired using a CBmicrouCT system constructed in the authors' laboratories. Dark- and flat-field corrections are performed. Exposure variations are detected and quantifled using analysis of image regions with an unobstructed view of the x-ray source. Translations that occur during the acquisition in the horizontal direction are detected, quantified, and corrected based on sinogram analysis. The axis of rotation is determined using registration of antiposed projection images. These techniques were evaluated using data obtained with calibration objects and phantoms. The physical geometric axis of rotation is determined and aligned with the rotational axis (assumed to be the center of the detector plane) used in the reconstruction process. The parameters describing this axis agree to within 0.1 mm and 0.3 deg with those determined using other techniques. Blurring due to residual calibration errors has a point-spread function in the reconstructed planes with a full-width-at-half-maximum of less than 125 microm in a tangential direction and essentially zero in the radial direction for the rotating object. The authors have used this approach on over 100 acquisitions over the past 2 years and have regularly obtained high-quality reconstructions, i.e., without artifacts and no detectable blurring of the reconstructed objects. This self-calibrating approach not only obviates calibration runs, but it also provides quality control data for each data set.

The 5/95 Gap on the dissemination of mental health research: The World Psychiatric Association (WPA) task force report on project with editors of low and middle income (LAMI) countries

The World Psychiatric Association (WPA) Task Force and a small group previously convened by the WPA publications committee initiated three activities between 2006-2008 that aimed to respond to the need for greater support for psychiatry journals in LAMI countries. In a joint venture with participants from the Global Mental Health Movement the Task Force editors from LAMI countries in Africa, Asia, Eastern Europe and Latin America were contacted to identify potential journals to target for indexation (Medline and ISI). The committee analyzed the editors' applications on the following criteria: a) geographical representativeness; b) affiliation to a professional mental health society; c) regular publication of at least 4 issues per year over the past few years; d) comprehensive national and international editorial boards; e) publication of original articles, or at least abstracts, in English; f) some level of current indexation; g) evidence of a good balance between original and review articles in publications; and h) a friendly access website. The committee received 26 applications (11 from Latin America, 7 from Central Europe, 4 from Asia and 4 from Africa), and selected 8 journals, 2 from each geographical area, on the basis of the overall scores obtained for the items mentioned, to participate in an editors meeting held in Prague in September 2008. The aims of the committee are twofold: a) to concentrate support for those selected journals; and b) to assist all LAMI mental health editors in improving the quality of their journals and fulfilling the requirements for full indexation. This report summarizes the procedures conducted by the committee, the assessment of the current non-indexed journals, and offers suggestions for further action.

Promoter hypermethylation of mismatch repair genes, hMLH1 and hMSH2 in oral squamous cell carcinoma

OBJECTIVES

Major risk factors of oral squamous cell carcinoma (OSCC) are environmental and can lead to DNA mutagenesis. Mismatch repair (MMR) system functions to repair small DNA lesions, which can be targeted for promoter hypermethylation. We therefore wanted to test whether hypermethylation of MMR genes (hMLH1, hMSH2) could contribute to oral carcinogenesis by correlating the information to patient clinical data.

METHODS

Genomic DNA was extracted from 28 OSCC and six normal oral epithelium samples. The methylation status of the two MMR genes was assessed using Methylation Specific PCR after DNA modification with sodium bisulfite. Serial sections of the same tissues were immunostained with antibodies against hMLH1 and hMSH2 protein.

RESULTS

Promoter hypermethylation was observed in 14/28 OSCC cases. Remarkably, 100% of patients with multiple oral malignancies showed hypermethylation in hMLH1 or hMSH2 compared with 31.5% of single tumor patients. In 10 cancer cases, expression of the hMLH1 and hMSH2 genes by immunostaining showed reduced or absence of expression of one of the genes, although some did not reflect the methylation status.

CONCLUSIONS

Hypermethylation of hMLH1 and hMSH2 might play a role in oral carcinogenesis and may be correlated with a tendency to develop multiple oral malignancies.

Gene expression in human oral squamous cell carcinoma is influenced by risk factor exposure

Oral squamous cell carcinoma (OSCC) is a world health problem and is associated with exposure to different risk factors. In the west, smoking and alcohol consumption are considered to be the main risk factors whilst in India and southeast Asia, betel quid (BQ) chewing is predominant. In this study, we compared the gene expression patterns of oral cancers associated with BQ chewing to those caused by smoking using Affymetrix microarrays. We found that 281 genes were differentially expressed between OSCC and normal oral mucosa regardless of aetiological factors including MMP1, PLAU, MAGE-D4, GNA12, IFITM3 and NMU. Further, we identified 168 genes that were differentially expressed between the BQ and smoking groups including CXCL-9, TMPRSS2, CA12 and RNF24. The expression of these genes was validated using qPCR using independent tissue samples. The results demonstrate that whilst common genes/pathways contribute to the development of oral cancer, there are also other gene expression changes that are specific to certain risk factors. The findings suggest that different carcinogens activate or inhibit specific pathways during cancer development and progression. These unique gene expression profiles should be taken into consideration when developing biomarkers for future use in prognostic or therapeutic applications.