JPMA. The Journal of the Pakistan Medical Association, 2015
To assess the knowledge and practices of general practitioners about diagnosis and treatment of s... more To assess the knowledge and practices of general practitioners about diagnosis and treatment of schizophrenia and determine their association with clinical exposure to such cases in practice. The cross-sectional study was conducted in Peshawar from August 2009 to December 2011 at the clinics of general practitioners enrolled with the provincial Health Regulation Authority. All the listed GPs were contacted and those consenting to participate were included. A semi-structured questionnaire was used to assess their knowledge and practices related to diagnosis and treatment of schizophrenia. They were categorised as having Good Knowledge/Practice, in this regard, when they responded to >60% of the questions correctly. Of the 135 general practitioners contacted, 114(84.5%) agreed to participate and represented the study sample. Of them, 61(53.5%) physicians did not treat any diagnosed case while 15(13.2%) treated more than 10(8.8%) annually. Only 6(5.3%) practitioners spent more than ...
Mental, behavioral and social health problems are an increasing part of the health burden on all ... more Mental, behavioral and social health problems are an increasing part of the health burden on all part of the globe. Countries like Pakistan are most affected because they are plagued by infectious diseases and chronic medical conditions. At the same time they are being afflicted by growing burden of mental health diseases and new social pathologies. Equally disastrous scenario is that we have great shortage of psychiatrists, which is not going to change in near future. In the light of above findings a curriculum of behavioral sciences including psychiatry for undergraduate medical students of Pakistan is outlined here.
We report a case of gender identity disorder in a 22 years old male, who confined himself to his ... more We report a case of gender identity disorder in a 22 years old male, who confined himself to his house, dressing, walking, talking and behaving like females. His testes were smaller than normal and his breasts were bigger than the normal size. He was taking estrogens and was reluctant to check his sexual hormone levels. He wanted to undergo genital reassignment and was in a regular contact with a transsexual that had already undergone genital reassignment surgery and was aiming to get married to a male. This created a social problem for parents, specially for his father.
Background: Schizophrenia affects 1% of population worldwide. In spite of its enormous impact, is... more Background: Schizophrenia affects 1% of population worldwide. In spite of its enormous impact, issues as basic as its diagnostic criteria remain ill-defined and controversial. Schneider claimed that in absence of somatic illness, first rank symptoms are pathognomonic of schizophrenia. However this claim has been criticized and first rank symptoms are reported to be present in other psychiatric disorders as well. The aim of this study was to see the prevalence of first rank symptoms in indoor schizophrenic patients in our set up.
Objectives: To find out the burden of care and associated mental health problems in caregivers of... more Objectives: To find out the burden of care and associated mental health problems in caregivers of patients with schizophrenia and epilepsy.
Objectives: To determine the usefulness of Schneider's first rank symptoms of schizophrenia. Meth... more Objectives: To determine the usefulness of Schneider's first rank symptoms of schizophrenia. Methodology: Patients suffering from schizophrenia, admitted to the Psychiatry Ward Khyber Teaching Hospital, Peshawar during the year 2009 were selected by non probability purposive sampling. It was a descriptive study and the diagnosis was made according to DSM-IV criteria. Patients were interviewed by using a semi structured questionnaire based on Present State Examination and first rank symptoms were assessed. Results: Out of 100 patients suffering from schizophrenia, there were 58 males and 42 females. Thirty four (34%) (22 male & 12 females) reported having one or more first rank symptoms while Sixty six (66%) patients although diagnosed with schizophrenia on DSM IV criteria did not show first rank symptoms. The most often found individual first rank symptoms in these 34 patients were voices commenting (n=14, %), made impulses (n=12, %), and voices arguing (n=12, %). None reported delusional perception.
Evidence for the effectiveness of Culturally adapted CBT for psychosis in Low And Middle Income C... more Evidence for the effectiveness of Culturally adapted CBT for psychosis in Low And Middle Income Countries (LAMIC) is limited. Therefore, brief Culturally adapted CBT for psychosis (CaCBTp) targeted at symptoms of schizophrenia for outpatients plus treatment as usual (TAU) is compared with TAU. A total of 116 participants with schizophrenia were recruited from 2 hospitals in Karachi, Pakistan, and randomized into two groups with 1:1 allocation (CaCBTp plus TAU = 59, TAU = 57). A brief version of CaCBTp (6 individual sessions with the involvement of main carer, plus one session for the family) was provided over 4 months. Psychopathology was measured using Positive and Negative Syndrome Scale of Schizophrenia (PANSS), Psychotic Symptom Rating Scales (PSYRATS), and the Schedule for Assessment of Insight (SAI) at baseline and end of therapy. Participants in treatment group, showed statistically significant improvement in all measures of psychopathology at the end of the study compared with control group. Participants in treatment group showed statistically significant improvement in Positive Symptoms (PANSS, Positive Symptoms Subscale; p = 0.000), Negative Symptoms (PANSS, Negative Symptoms subscales; p = 0.000), Delusions (PSYRATS, Delusions Subscale; p = 0.000), Hallucinations (PSYRATS, Hallucination Subscale; p = 0.000) and Insight (SAI; p = 0.007). The results suggest that brief, Culturally adapted CBT for psychosis can be an effective treatment when provided in combination with TAU, for patients with schizophrenia in a LAMIC setting. This is the first trial of CBT for psychosis from outside the western world. These findings need replicating in other low and middle income countries.
Mental health is more than the absence of mental disorders but it has not been given the same imp... more Mental health is more than the absence of mental disorders but it has not been given the same importance as physical health in most parts of the world. Pakistan, a lower middle income country, spending only 0.4% of the total health budget on mental health can be quoted as an example. Still, Pakistan is among those 60% of the countries that have a mental health policy. This article is an attempt to explain the concept and need of mental health policy and the implementation of mental health policy in Pakistan.
Methodology: This cross-sectional study was conducted at Jalalah Camp in Mardan District with 10,... more Methodology: This cross-sectional study was conducted at Jalalah Camp in Mardan District with 10,500 displaced persons from June to August 2009. A questionnaire based on sphere handbook was administered to heads of 128 families using systematic random sampling. Camp administration and providers of different facilities in the camp were also interviewed to assess psychosocial support available.
Objective: To compare the frequency of postnatal depression in women following Normal Vaginal Del... more Objective: To compare the frequency of postnatal depression in women following Normal Vaginal Delivery and Caesarian Section.
Objective: To objectively assess whether the medical education environment across Pakistan was at... more Objective: To objectively assess whether the medical education environment across Pakistan was at an acceptable standard and to determine factors influencing its perception. Methods: The cross-sectional study was conducted from August to November 2012 at six undergraduate medical institutions across Pakistan. The Dundee Ready Education Environment Measure (DREEM) inventory having five subscales of perceptions of learning, teachers, atmosphere, academic self-perceptions and social self-perceptions was administered anonymously to all the consenting medical students. Data was analysed using SPSS 17. Result: Of the 3045 questionnaires distributed, 2084(68.4%) were returned duly filled. Of all the respondents, 1311(63%) were females. Overall mean score found positive was 105. 0±25.8 (Max: 200). Corresponding scores in the subscales were: student's perception of learning 25.1±7.2 (Max: 48); social self-perception 15.4±3.9 (Max: 28); academic self-perception17.2±6.5 (Max: 32); perception of teachers being in need of some re-training 22.5±7.1 (Max: 44); and perception of atmosphere as having many issues needing a change 24.8±7.0 (Max: 48). Female students and pre-clinical year students perceived environment as more positive than male students (108.6±23.0 vs. 98.8±28.9 [p<0.001]) and students belonging to clinical years (108.0±24.0 vs. 03.3±26.5 [p<0.001]). Conclusion: Highest score was found in the domain of student's social self-perceptions and lowest in the domain of student's perception of teachers. Results can be used as a basis for planning and executing remedial measures needed to improve undergraduate medical education environment in Pakistan.
Objective: To estimate the direct and indirect cost of depressive disorders in indoor patients. M... more Objective: To estimate the direct and indirect cost of depressive disorders in indoor patients. Methodology: This hospital based descriptive study was carried out on thirty patients admitted consecutively in department of psychiatry Jinnah Postgraduate Medical Center Karachi from January to July 2000. International Classification of Disease-10 diagnostic criteria for depressive disorders were used to identify the patients. Cost proforma was devised to calculate direct and indirect cost. The cost of hospital stay per day was calculated by using opportunity costs model. Results: There were 9 (30%) male and 21 (70%) female patients. Majority of the patients were in their twenties (n=11, 36.67%) and thirties (n=9, 30%). There were 24 (80.02%) married and 6 (19.98%) unmarried patients. A total of 20 (66.66%) were jobless and 10 (33.33%) were having a job. Most of the patients were suffering from moderate depressive disorder and recurrent depressive disorder (n=11, 36.67% and n=10, 33.33%). The overall cost of all the patients was Rs. 472,542 with Rs.73,026 (15%) in direct and Rs. 399,516 (85%) in indirect costs with a ratio of 1:5.5.
Objective: To test the reliability and applicability of Urdu translation of the International per... more Objective: To test the reliability and applicability of Urdu translation of the International personality disorder examination (IPDE) in a psychiatric outpatient population in Pakistan. Methods: This study was conducted at the outpatient department of Fatima Memorial Hospital Lahore from April 2012 to March 2013. Patients considered to have a personality disorder by a psychiatrist were initially screened by the IPDE screening questionnaire. Those who scored positive on screening were evaluated in a detailed interview using IPDE. Two interviewers conducted the interviews simultaneously, to ensure inter-rater reliability. For translation, permission was taken from World Health Organization. Linguistic equivalence was assessed through back-translation and conceptual equivalence through opinion of mental health experts. The final Urdu draft was obtained after incorporating modifications suggested by experts following a feasibility study. The analysis was carried out using SPSS v.20. Results: Out of 30 enrolled patients, 25(83.3%) were females. The mean age of the sample was 28.5+6.08 years. Majority of patients had more than one personality disorder. Most prevalent personality disorder was emotionally unstable borderline type with a phi correlation of 0.831, followed by emotionally unstable impulsive type and anankastic personality disorder with phi correlations of 0.930 and 0.867, respectively, for definite cases. Correlation coefficient for dimensional scores between the two raters was 0.392 for paranoid personality disorder, 0.842 for anankastic and around 0.9 for the rest of the personality disorders, each. Conclusion: Urdu translation of IPDE is a reliable tool to screen and diagnose personality disorders in population of Pakistan.
Brief Culturally adapted CBT(CaCBT) for depression: A randomized controlled trial from Pakistan
Journal of Affective Disorders
To determine the efficacy of brief Culturally adapted CBT (CaCBT) for depression when added to Tr... more To determine the efficacy of brief Culturally adapted CBT (CaCBT) for depression when added to Treatment As usual (TAU)-delivered by trained therapists using a manual compared with alone TAU. This was an assessor-blinded, randomised controlled clinical trial. Particpants with a diagnosis of depression, attending psychiatry departments of three teaching hospitals in Lahore, Pakistan, were included in the study. We screened a total of 280 patients and randomly allocated 137 of them to CaCBT plus Treatment As Usual (TAU) [Treatment group] or to TAU alone [Control group]. Assessments were completed at baseline, at 3 months and at 9 months after baseline. Reduction in depression score (Hospital Anxiety and Depression-Depression Subscale) at 3 months was primary outcome measure. The secondary outcome measures included anxiety scores (Hospital Anxiety and Depression-Anxiety Subscale), somatic symptoms (Bradford Somatic Inventory), disability (Brief Disability Questionnaire) and satisfaction with the treatment. A total of 69 participants were randomised to Treatment group and 68 to Control group. Participants in Treatment group showed statistically significant improvement in depression (p=0.000), anxiety (p=0.000), somatic symptoms (p=0.005) and disability (p=0.000). This effect was sustained at 9 months after baseline (Except for disability). Participants in Treatment group also reported higher satisfaction with treatment compared with those in Control group. Brief CaCBT can be effective in improving depressive symptoms, when compared with treatment as usual. This is the first report of a trial of Culturally adapted CBT from South Asia and further studies are needed to generalise these findings.
Background: Schizophrenia is a devastating disorder not only for the patients but also for their ... more Background: Schizophrenia is a devastating disorder not only for the patients but also for their caregivers. The caregivers of the patients suffer from psychological distress but receive minimum support from psychiatric services. Objectives were to assess the stress level in caregivers of patients with schizophrenia and to determine the association of stress with demographic variables of caregivers. Methods: It was a descriptive hospital based study carried out in Psychiatry Department of Khyber Teaching Hospital, Peshawar. Fifty caregivers were included in the study during a period of one year. Socio-demographic variables were recorded on specially designed pro forma. Stress level was assessed by using Self Report Questionnaire (SRQ-20) with a cut off score of 9 being taken as stressed. Results: Mean age of the caregivers was 45.44±14.25 years. Forty-two (84%) caregivers were males and 8 (16%) were females. Twenty-eight (56%) were uneducated, 16 (32%) had Primary education, 4 (8%) were matriculates and 2 (4%) graduates. Thirty-four (68%) of the caregivers were married 8 (16%each unmarried and widows/widowers. Thirty-two (64%) were unemployed and 18 (36%) were employed. Two (4%) had been providing care for less than 6 months, 4 (8%) for less than 12 months, 10 (20%) for less than 18 months, 2 (4%) for less than 24 months and 32 (64%) for more than 24 months. 22 (44%) were parents, 14 (28%) were siblings, 2 (4%) were children of the patients. Thirty-six (72%) caregivers were having score of more than 9 on SRQ-20. Stress showed a statistically significant association only with age (p-value <0.004). Conclusion: Psychological distress is present in majority of the caregivers of patients with schizophrenia. There is statistically significant association between age of the caregiver and psychological distress, while gender, educational status, marital status, occupational status, duration of care and relation with the patient are not associated with psychological distress.
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Papers by Muhammad Irfan