Theory-driven development of a mobile phone supported intervention for adolescents with perinatal depression

Purpose

This paper describes the design of a theory-informed pragmatic intervention for adolescent perinatal depression in primary care in Nigeria.

Methods

We conducted Focus Group Discussions (FGDs) among 17 adolescent mothers and 25 maternal health care providers with experience in the receipt and provision of care for perinatal depression. The Consolidated Framework for Implementation Research (CFIR) was used to systematically examine the barriers and facilitators affecting adolescent mothers' use of an existing intervention package for depression. The Theoretical Domain Framework (TDF) and the Capability, Opportunity, Motivation, Behaviour (COM-B) model were used to analyze the results of the data across the five CFIR domains.

Results

FGD analysis revealed that care providers lacked knowledge on approaches to engage young mothers in treatment. Young mothers had poor treatment engagement, low social support, and little interest in parenting. A main characteristic of the newly designed intervention is the inclusion of age-appropriate psychoeducation supported with weekly mobile phone calls, to address treatment engagement and parenting behaviours of young mothers. Also in the outer setting, low social support from relatives was addressed with education, “as need arises” phone calls, and the involvement of "neighborhood mothers”. In the inner settings, care providers’ behaviour is addressed with training to increase their capacity to engage young mothers in treatment.

Conclusion

A theory-based approach helped develop an age-appropriate intervention package targeting depression and parenting skills deficit among perinatal adolescents in primary maternal care and in which a pragmatic use of mobile phone was key.

     

Apolipoprotein E—associated risk for Alzheimer's disease in the African-American population is genotype dependent

As a part of our ongoing study on Alzheimer's disease (AD) in elderly African Americans, we obtained clinical assessment and apolipoprotein E (ApoE) genotype data on 288 individuals (including 60 with AD). The ApoE σ4 allele frequency was significantly increased in AD patients compared with controls. The age-adjusted odds ratio (OR) for AD in σ4 homozygotes was 4.83 (95% confidence interval [CI], 1.71–13.64) compared with the σ3/σ3 genotype, but the OR for AD with the σ3/σ4 genotype did not reach significance (1.20; 95% CI, 0.58–2.45). These findings suggest that the association between ApoE σ4 and AD is weaker in African Americans than in whites.     

Physician performance of laboratory tests in self-service facilities. Residents' perceptions and performance

Primary care physicians perform simple laboratory tests in clinical practice, frequently with little formal training. To determine the frequency of tests that are performed and evaluate house officer laboratory skills, we surveyed house officer attitudes and tested their ability to perform four common laboratory tests. We received 193 responses from 254 house officers at one university teaching hospital. While most perceived the need to use ward laboratories (ie, self-service laboratories located on patient care wards), 67% used them infrequently. Barriers included poor laboratory condition, inadequate time, accuracy, and infectious exposure concerns. Twenty-four percent felt they did not know or were unsure if they knew how to perform simple tests. Forty-seven house officers completed the practical examination. Most accurately reported a spun hematocrit and correctly identified white blood cell findings on a blood smear. Only 50% counted 100 cells. Urinary dipstick interpretation was generally acceptable but the microscopic examination was less accurate. Twenty-three percent failed to identify gram-negative rods on a slide with both gram-positive cocci and gram-negative rods. If physicians are to perform selected laboratory tests, these data suggest, at least in one institution, more formal training, practice, and evaluation are necessary to ensure their performance with adequate proficiency.     

Adenosine 3',5'-cyclic monophosphate in perfused rat hearts exposed to isoprenaline and dopamine.

Isoprenaline and dopamine increased cyclic AMP (cAMP) content and contractile activity of isolated perfused rat hearts. The changes of cAMP levels depended on the mode of drug administration. Isoprenaline (4 x 10(-10) mol) administered to the perfused heart as a relatively concentrated bolus, caused a substantial, rapid and transient increase of cAMP. Isoprenaline (2 x 10(-10) mol and 4 x 10(-10) mol) and dopamine (10(-7) mol) diluted in 40 ml of perfusate which was continuously recirculated through the heart, caused a gradual increase of cAMP content which approached an apparent steady state. cAMP accumulation occurred at isoprenaline concentrations above 10(-9) M and at dopamine concentrations above 10(-6) M. Both agents also increased cAMP labelling from 14C-adenine in the perfusate, probably indicating increased cAMP synthesis. Isoprenaline at 2 x 10(-8) M and 10(-7) M increased labelling more than content of cAMP. Isoprenaline and dopamine also increased phosphorylase a activity. An association between increased cAMP contents and increased contractile activity was revealed by both the time-response and the dose-response curves of hearts exposed to isoprenaline and dopamine. Since both agents stimulate adrenergic beta-receptors in cardiac muscle, the results are concordant with the hypothesis that cAMP is involved as a mediator of the inotropic response to adrenergic beta-stimulation.     

Use of specimen turnaround time as a component of laboratory quality. A comparison of clinician expectations with laboratory performance

Quantitative laboratory quality measures include test accuracy and precision. To be useful, however, tests also must be available in a timely manner. The authors surveyed 757 University of California, Los Angeles, house officers (485-64% responded) regarding their expectations of laboratory test turnaround time for five test groups that are regularly offered both stat and routine. They compared expectations with actual laboratory performance by evaluating turnaround time for 42,414 consecutive laboratory requests received over two weeks. The authors' laboratory performed 45% of studied analytes stat. Median turnaround time was 44 minutes for stat and 119 minutes for routine tests, although variation exists by test group. The percentage of time their laboratory met median stat and routine turnaround time expectations varies by shift and work area. Timeliness of results often may be as important as accuracy and precision in assuring quality of care and cost-effective use of hospital services. Although the laboratory may not meet current housestaff turnaround time expectations, it is unclear whether laboratory performance is inadequate or housestaff expectations are unreasonable. Publicizing actual routine turnaround times may reduce the number of stat requests ordered if routine turnaround times are incorrectly perceived to be too slow. Reduction in stat test ordering may improve overall laboratory performance and turnaround time. The authors recommend that clinical pathologists and clinicians together develop turnaround time goals based on practicality, medical necessity, and clinician expectations.     

The significance of subtyping tardive dyskinesia: a study of prevalence and associated factors

The prevalence of tardive dyskinesia (TD) in 137 Nigerian psychiatric patients was 27%. There were no differences in the prevalence rate between patients with affective disorder and those with schizophrenia. There were also no significant differences between the sexes but a trend for the more severe forms of dyskinesia to be commoner in females was noticed. Demographic, clinical and treatment variables were investigated for association with TD and each of its two putative subsyndromes: orofacial and appendicular dyskinesias. Two cases of severe and persistent tardive dystonia, associated with orofacial TD, were seen in two young adults, one with relatively short exposure to neuroleptics. After initial univariate screening, multivariate statistical methods revealed that different factors were associated with each of the two subsyndromes. While length of hospitalization correlated significantly with orofacial dyskinesia, cumulative duration of exposure to high-potency neuroleptics and number of ECTs received were significantly associated with appendicular TD. Neither age nor sex correlated with either of the subsyndromes. The findings confirm and extend previous observations suggesting that these dyskinesias may involve different pathophysiological mechanisms.     

Tardive dyskinesia in schizophrenics. Prevalence, distribution and relationship to neurological "soft" signs in Nigerian patients

The prevalence of tardive dyskinesia (TD) in 70 Nigerian schizophrenics was 37%. Age was related to the presence of TD in males but not in females. Significantly more females had TD in the lower extremities. Comparison of patients with TD and those without revealed no significant differences with regard to the presence of neurological "soft" signs.     

Effects of (S)-ketamine on striatal dopamine: a [11C]raclopride PET study of a model psychosis in humans

Administration of the N-methyl-D-aspartate (NMDA) antagonist S-ketamine in normals produces a psychosis-like syndrome including several positive and negative symptoms of schizophrenic disorders (Abi-Saab WM, D'Souza DC, Moghaddam B, Krystal JH. The NMDA antagonist model for schizophrenia: promise and pitfalls. Pharmacopsychiatry 1998;31:104-109). Given the clinical efficacy of dopamine (DA) D2 receptor antagonists in the treatment of positive symptoms, it is conceivable that S-ketamine-induced psychotic symptoms are partially due to a secondary activation of dopaminergic systems. To date, animal and human studies of the effects of NMDA antagonists on striatal DA levels have been inconsistent. The present study used positron emission tomography (PET) to determine whether a psychotomimetic dose of S-ketamine decreases the in vivo binding of [11C]raclopride to striatal DA D2 receptors in humans (n = 8). S-ketamine elicited a psychosis-like syndrome, including alterations in mood, cognitive disturbances, hallucinations and ego-disorders. S-ketamine decreased [11C]raclopride binding potential (BP) significantly in the ventral striatum (-17.5%) followed by the caudate nucleus (-14.3%) and putamen (-13.6%), indicating an increase in striatal DA concentration. The change in raclopride BP in the ventral striatum correlated with heightened mood ranging from euphoria to grandiosity. These results provide evidence that the glutamatergic NMDA receptor may contribute to psychotic symptom formation via modulation of the DA system.     

Traumatic events and suicidal behaviour in the Nigerian Survey of Mental Health and Well‐Being

Uwakwe R, Oladeji BD, Gureje O. Traumatic events and suicidal behaviour in the Nigerian Survey of Mental Health and Well‐Being. Objective: Not much is known about the role of different traumatic events in predicting suicidal outcomes. We investigated the association of specific traumatic events with different suicidal outcomes. Method: Data are from the Nigerian Survey of Mental Health and Well‐Being, a multistage probability household survey of persons aged 18 years and over. Information on traumatic events and suicidal behaviours (ideation, plan and attempts) was collected in face‐to‐face interviews using the Composite International Diagnostic Interview (CIDI.3) from a subsample of the respondents (N = 2143). Results: At least one traumatic event was reported by 63% of the sample. Traumatic events were more likely to have been experienced by individuals with different suicidal outcomes, with a dose–response relationship between the number of traumatic events and suicide ideation. The risks of suicidal ideation were elevated among persons with a history of combat experience (OR 6.3 95% CI 1.8–21.8) and those with exposure to war (OR 4.2; 95% CI 1.6–10.6), while that of suicidal attempt was increased among persons with experience of interpersonal violence (OR 4.3; 95% CI 1.4–13.0). Conclusion: Traumatic events are common in the general population. This report highlights the role of traumatic events (especially those related to violence) in predicting suicidal behaviour.