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The 2008 economic recession was associated with an increase in suicide internationally. Studies have focused on the impact in the general population with little consideration of the effect on people with a mental illness.
To investigate suicide trends related to the recession in mental health patients in England.
Using regression models, we studied suicide trends in mental health patients in England before, during and after the recession and examined the demographic and clinical characteristics of the patients. We used data from the National Confidential Inquiry into Suicide and Safety in Mental Health, a national data-set of all suicide deaths in the UK that includes detailed clinical information on those seen by services in the last 12 months before death.
Between 2000 and 2016, there were 21 224 suicide deaths by patients aged 16 or over. For male patients, following a steady fall of 0.5% per quarter before the recession (quarterly percent change (QPC) 2000–2009 –0.46%, 95% CI –0.66 to –0.27), suicide rates showed an upward trend during the recession (QPC 2009–2011 2.37%, 95% CI –0.22 to 5.04). Recession-related rises in suicide were found in men aged 45–54 years, those who were unemployed or had a diagnosis of substance dependence/misuse. Between 2012 and 2016 there was a decrease in suicide in male patients despite an increasing number of patients treated. No significant recession-related trends were found in women.
Recession-associated increases in suicide were seen in male mental health patients as well as the male general population, with those in mid-life at particular risk. Support and targeted interventions for patients with financial difficulties may help reduce the risk at times of economic hardship. Factors such as drug and alcohol misuse also need to be considered. Recent decreases in suicide may be related to an improved economic context or better mental healthcare.
Declaration of interest
N.K. is supported by Greater Manchester Mental Health NHS Foundation Trust. L.A. chairs the National Suicide Prevention Strategy Advisory Group at the Department of Health (of which N.K. is also a member) and is a non-executive Director for the Care Quality Commission. N.K. chairs the National Institute for Health and Care Excellence (NICE) depression in adults guideline and was a topic expert member for the NICE suicide prevention guideline.
There is a scarcity of specialist trainers and supervisors for psychosocial interventions in low- and middle-income countries. A cascaded model of training and supervision was developed to sustain delivery of an evidence-based peer-delivered intervention for perinatal depression (the Thinking Healthy Programme) in rural Pakistan. The study aimed to evaluate the model.
Mixed methods were employed as part of a randomised controlled trial of the intervention. Quantitative data consisted of the peers' competencies assessed during field training and over the implementation phase of the intervention, using a specially developed checklist. Qualitative data were collected from peers and their trainers through 11 focus groups during the second and third year of intervention rollout.
Following training, 43 peers out of 45 (95%) achieved at least a ‘satisfactory’ level of competency (scores of ⩾70% on the Quality and Competency Checklist). Of the cohort of 45 peers initially recruited 34 (75%) were retained over 3 years and showed sustained or improved competencies over time. Qualitatively, the key factors contributing to peers' competency were use of interactive training and supervision techniques, the trainer–peer relationship, and their cultural similarity. The partnership with community health workers and use of primary health care facilities for training and supervision gave credibility to the peers in the community.
The study demonstrates that lay-workers such as peers can be trained and supervised to deliver a psychological intervention using a cascaded model, thus addressing the barrier of scarcity of specialist trainers and supervisors.
We evaluated the performance of three serological tests – an immunoglobulin G indirect enzyme linked immunosorbent assay (iELISA), a Rose Bengal test and a slow agglutination test (SAT) – for the diagnosis of bovine brucellosis in Bangladesh. Cattle sera (n = 1360) sourced from Mymensingh district (MD) and a Government owned dairy farm (GF) were tested in parallel. We used a Bayesian latent class model that adjusted for the conditional dependence among the three tests and assumed constant diagnostic accuracy of the three tests in both populations. The sensitivity and specificity of the three tests varied from 84.6% to 93.7%, respectively. The true prevalences of bovine brucellosis in MD and the GF were 0.6% and 20.4%, respectively. Parallel interpretation of iELISA and SAT yielded the highest negative predictive values: 99.9% in MD and 99.6% in the GF; whereas serial interpretation of both iELISA and SAT produced the highest positive predictive value (PPV): 99.9% in the GF and also high PPV (98.9%) in MD. We recommend the use of both iELISA and SAT together and serial interpretation for culling and parallel interpretation for import decisions. Removal of brucellosis positive cattle will contribute to the control of brucellosis as a public health risk in Bangladesh.
This paper investigates the passive and active control strategies to provide a physical assistance and rehabilitation by a 7-DOF exoskeleton robot with nonlinear uncertain dynamics and unknown bounded external disturbances due to the robot user's physiological characteristics. An Integral backstepping controller incorporated with Time Delay Estimation (BITDE) is used, which permits the exoskeleton robot to achieve the desired performance of working under the mentioned uncertainties constraints. Time Delay Estimation (TDE) is employed to estimate the nonlinear uncertain dynamics of the robot and the unknown disturbances. To overcome the limitation of the time delay error inherent of the TDE approach, a recursive algorithm is used to further reduce its effect. The integral action is employed to decrease the impact of the unmodeled dynamics. Besides, the Damped Least Square method is introduced to estimate the desired movement intention of the subject with the objective to provide active rehabilitation. The controller scheme is to ensure that the robot system performs passive and active rehabilitation exercises with a high level of tracking accuracy and robustness, despite the unknown dynamics of the exoskeleton robot and the presence of unknown bounded disturbances. The design, stability, and convergence analysis are formulated and proven based on the Lyapunov–Krasovskii functional theory. Experimental results with healthy subjects, using a virtual environment, show the feasibility, and ease of implementation of the control scheme. Its robustness and flexibility to deal with parameter variations due to the unknown external disturbances are also shown.
The self-learning kinetic Monte Carlo method has been shown to be suitable for examining the temporal and spatial evolution of adatom islands on the (111) surface of several fcc metals, unbiased by diffusion processes chosen a priori. A pattern-recognition scheme and a diffusion path finder scheme enable collection of a large database of diffusion processes and their energetics. A variety of mechanisms involving single and multiple atoms, and concerted island motion are uncovered in long-time simulations. In this contribution, after reviewing the methodology, we present results comparing the diffusion kinetics of two sets of homo-epitaxial and hetero-epitaxial systems: small (2–8 atom) Pd and Ag islands on the respective (111) surfaces and small Cu islands on Ni(111) and Ni islands on Cu(111). We trace the dominance of concerted motion in Pd/Pd(111) and Ni/Cu(111) and competition among concerted, multiatom and single-atom processes in Ag/Ag(111) and Cu/Ni(111) to the strength of the lateral interaction among adatoms in these systems.
Tropical bamboos persist in a wide range of light conditions and quickly respond to changes in light availability. However, the mechanisms underpinning this ability remain unknown. In order to test the hypothesis that the modular and hollow culm architecture of bamboos explains their performance in a wide range of light environments, we determined the allometric relationships of two dominant bamboo species of the upper hill dipterocarp forests of Malaysia, Gigantochloa ligulata (n = 29) and Schizostachyum grande (n = 25), via destructive sampling. We also monitored biomass turnover of bamboos and woody trees in 24 permanent plots (1.92 ha in total) over a one-year period. Compared with woody trees, bamboo culms attained 1.5 times the height and their clumps supported four times as much total leaf area at the same above-ground biomass. In addition, at a given height, bamboo clumps had six times larger crown projection area than trees while having a similar amount of total leaf area per unit of crown projection area. Finally, bamboos’ biomass turnover rate was three times higher than trees, and G. ligulata increased its specific rate of biomass increase after canopy disturbance, while trees decreased. We conclude that the unique architecture of bamboos allows them to persist under closed forest canopy light conditions and to respond to gap formation via high biomass turnover rate.
We are a group of researchers and clinicians with collective experience in child survival, nutrition, cognitive and social development, and treatment of common mental conditions. We join together to welcome an expanded definition of child development to guide global approaches to child health and overall social development. We call for resolve to integrate maternal and child mental health with child health, nutrition, and development services and policies, and see this as fundamental to the health and sustainable development of societies. We suggest specific steps toward achieving this objective, with associated global organizational and resource commitments. In particular, we call for a Global Planning Summit to establish a much needed Global Alliance for Child Development and Mental Health in all Policies.
The Eastern Gangetic Plain is among the world's most intensively farmed regions, where rainfed and irrigated agriculture coexist. While the region and especially Bangladesh is a major producer of rice (Oryza sativa L. ssp. indica), there is potential to further develop sustainable rice production systems. Specifically, there is scope to include a replacement crop for the short fallow between rice crops in the dominant cropping pattern of rainfed monsoon rice harvest followed by irrigated spring rice. The aim of the current research was to identify a suitable cool-season legume crop – pea (Pisum sativum L.) or lentil (Lens culinaris Medik. ssp. culinaris) – that could be grown in the brief period between rice crops. The study comprised four crop sequence experiments comparing legume cultivars differing in maturity grown in between both long and short duration rice cultivars. These experiments were done at the Bangladesh Rice Research Institute regional station at Rajshahi over three cropping cycles. This was followed by an evaluation of pea vs. fallow between rice crops on three farmers’ fields in one cropping cycle. Here it is demonstrated that green pod vegetable pea is one of the best options to intensify the rainfed monsoon rice–fallow–spring irrigated rice cropping system, notwithstanding other remunerative rabi cropping options that could displace boro rice. The inclusion of an extra crop, pea as green pod vegetable, increased farm productivity by 1·4-fold over the dominant cropping sequence (rice–fallow–rice) and farm net income by fourfold. The study highlighted the advantages in total system productivity and monetary return of crop intensification with the inclusion of a pea crop between successive rice crops instead of a fallow period.
The aim of this feasibility trial was to evaluate the feasibility and acceptability of the locally adapted Group Problem Management Plus (PM+) intervention for women in the conflict affected settings in Swat, Pakistan.
This mixed-methods study incorporated a quantitative component consisting of a two arm cluster randomised controlled feasibility trial, and qualitative evaluation of the acceptability of the Group PM+ to a range of stakeholder groups. For the quantitative component, on average from each of the 20 Lady Health Workers (LHWs) catchment area (20 clusters), six women were screened and recruited for the trial with score of >2 on the General Health Questionnaire and score of >16 on the WHO Disability Assessment Schedule. These LHW clusters were randomised on a 1 : 1 allocation ratio using a computer-based software through a simple randomisation method to the Group PM+ intervention or Enhanced Usual Care. The Group PM+ intervention consisted of five weekly sessions of 2 h duration delivered by local non-specialist females under supervision. The primary outcome was individual psychological distress, measured by levels of anxiety and depression on the Hospital Anxiety and Depression Scale at 7th week after baseline. Secondary outcomes include symptoms of depression, post-traumatic stress disorder (PTSD), general psychological profile, levels of functioning and generalised psychological distress. Intervention acceptability was explored through in-depth interviews.
The results show that lay-helpers with no prior mental health experience can be trained to achieve the desired competency to successfully deliver the intervention in community settings under supervision. There was a good intervention uptake, with Group PM+ considered useful by participants, their families and lay-helpers. The outcome evaluation, which was not based on a large enough study to identify statistically significant results, indicated statistically significant improvements in depression, anxiety, general psychological profile and functioning. The PTSD symptoms and depressive disorder scores showed a trend in favour of the intervention.
This trial showed robust acceptance in the local settings with delivery by non-specialists under supervision by local trained females. The trial paves the way for further adaptation and exploration of the outcomes through larger-scale implementation and definitive randomised controlled trials in the local settings.
Development disorders and delays are recognised as a public health priority and included in the WHO mental health gap action programme (mhGAP). Parents Skills Training (PST) is recommended as a key intervention for such conditions under the WHO mhGAP intervention guide. However, sustainable and scalable delivery of such evidence based interventions remains a challenge. This study aims to evaluate the effectiveness and scaled-up implementation of locally adapted WHO PST programme delivered by family volunteers in rural Pakistan.
The study is a two arm single-blind effectiveness implementation-hybrid cluster randomised controlled trial. WHO PST programme will be delivered by ‘family volunteers’ to the caregivers of children with developmental disorders and delays in community-based settings. The intervention consists of the WHO PST along with the WHO mhGAP intervention for developmental disorders adapted for delivery using the android application on a tablet device. A total of 540 parent-child dyads will be recruited from 30 clusters. The primary outcome is child's functioning, measured by WHO Disability Assessment Schedule – child version (WHODAS-Child) at 6 months post intervention. Secondary outcomes include children's social communication and joint engagement with their caregiver, social emotional well-being, parental health related quality of life, family empowerment and stigmatizing experiences. Mixed method will be used to collect data on implementation outcomes. Trial has been retrospectively registered at ClinicalTrials.gov (NCT02792894).
This study addresses implementation challenges in the real world by incorporating evidence-based intervention strategies with social, technological and business innovations. If proven effective, the study will contribute to scaled-up implementation of evidence-based packages for public mental health in low resource settings.
Registered with ClinicalTrials.gov as Family Networks (FaNs) for Children with Developmental Disorders and Delays. Identifier: NCT02792894 Registered on 6 July 2016.
Bangladesh is a country with a high burden of micronutrient malnutrition. Stunting affects 41 % of children aged under 5 years. Zn is one of the key micronutrients that is associated with stunting. The present study, as part of the national micronutrient survey 2011–2012, revealed for the first time the nationally representative prevalence of Zn deficiency and determined the associations of the condition. A cross-sectional ‘nationwide’ survey was conducted in pre-school-age children (6–59 months; PSAC) and non-pregnant non-lactating women (15–49 years; NPNLW). Multistage random sampling was done in 150 clusters; fifty in each of the rural, urban and slum strata. Data were analysed on 662 PSAC and 1073 NPNLW. Serum Zn was assayed by atomic absorption spectrophotometry. Zn deficiency was defined as serum Zn of <9·9 and <10·1 µmol/l in PSAC and NPNLW, respectively. The national prevalence of Zn deficiency was 44·6 and 57·3 % in PSAC and NPNLW, respectively. In PSAC, it was 29·5, 48·6 and 51·7 %, respectively, in urban, rural and slum strata. Household expenses (β = 0·13; P = 0·007), Hb (β = 0·10; P = 0·005), intake of animal-source Zn (β = 0·096; P = 0·02) and asset score (β = 0·11; P = 0·03) were positively associated with serum Zn in NPNLW. Residence in an urban area (β = 0·33; P = 0·03) and intake of plant-origin Zn (β = −0·13; P = 0·038) determined higher and lower status of Zn in PSAC, respectively. Zn deficiency was highly prevalent in Bangladesh, and it was principally related to inadequate quality of diet. To improve Zn nutrition, Bangladesh needs to strengthen research and programmes related to Zn biofortification, fortification and phytate-reducing technologies in the food system in the short and medium term. In addition, promotion of animal-source Zn for all is important in the long run.
Introduction: Syncope can be caused by serious life-threatening conditions not obvious during the initial ED assessment leading to wide variations in management. We aimed to identify the reasons for consultations and hospitalizations, outcomes, and the potential cost savings if an outpatient cardiac monitoring strategy were developed. Methods: We conducted a prospective cohort study of adult syncope patients at 5 academic EDs over 41 months. We collected baseline characteristics, reasons for consultation and hospitalization, hospital length of stay and average total inpatient cost. Adjudicated 30-day serious adverse events (SAEs) included death, myocardial infarction, arrhythmia, structural heart disease, pulmonary embolism, significant hemorrhage and procedural intervention. We used descriptive statistics with 95% CI. Results: Of the 4,064 patients enrolled (mean age 53.1 years, 55.9% female), 3,255 (80.1%) were discharged from the ED, 209 (5.2%) had a SAE identified in the ED, 600 (14.8%) with no SAE were referred for consultation in the ED and 299 (7.4%) were hospitalized: 55.5% of referrals and 55.2% of hospitalizations were for suspected cardiac syncope (46.5% admitted for cardiac monitoring of whom 71.2% had no cause identified). SAE among groups were 9.7% in total; 2.5% discharged by ED physician; 3.4% discharged by consultant from ED; 21.7% as inpatient and 4.8% following discharge from hospital. The mean hospital length of stay for cardiac syncope was 6.7 (95%CI 5.8, 7.7) days with total estimated costs of $7,925 per patient (95% CI: 7434, 8417). Conclusion: Suspected cardiac syncope, particularly arrhythmia, was the major reason for ED referral and hospitalization. The majority of patients hospitalized for cardiac monitoring had no identified cause. An important number of patients suffered SAE, particularly arrhythmias outside the hospital. These findings highlight the need to develop a robust syncope prediction tool and a remote cardiac monitoring strategy to improve patient safety while saving substantial health care resources.
Conservation agriculture (CA) is inadequately developed for rice-based cropping systems widely practiced in Bangladesh. The current drawback is the implementation of CA for all crops including rice (Oryza sativa L., ecotype ‘transplanted aman’ [T. aman]) to increase rice–wheat (Triticum aestivum L.) rotation productivity. It is important to identify the best combination of tillage types and cropping systems to achieve a high yield of component crops and improve soil health. Three tillage practices, assigned to main experimental plots [namely, zero tillage (ZT), conventional tillage using a rotary tiller (CT) and deep tillage using a chisel plough (DT)] and three different cropping systems, assigned to sub-plots [namely, WFT: wheat–fallow–T. aman, WMT: wheat–mungbean (Vigna radiata L. Wilczek)–T. aman and WDT: wheat–dhaincha (Sesbania rostrata)–T. aman], were tested. After 4 years, ZT under WDT and WMT significantly increased soil organic matter (SOM) at 0–150 mm depth, and these replicates also held the highest levels of total organic carbon. Soil organic carbon (C) increased at a rate of 1.17 and 1.14 t/ha/y in ZT under WDT and WMT, respectively, while CT and DT under WFT were almost unchanged. After 4 years, SOM build-up by the three-crop system (WDT and WMT) under ZT helped conserve soil moisture and improve other soil properties, such as reduction in soil strength and bulk density and increase plant available water content, thus maintaining an optimum soil water infiltration rate. Zero tillage under WMT and WDT showed significant improvements in root mass density of rice and wheat at increased soil depth. The WDT and WMT plots under DT consistently gave the highest yield followed by WDT and WMT under CT, in contrast with ZT under WMT or WDT, which showed the highest improvement in crop yields over the years. In summary, minimum soil disturbance together with incorporation of a legume/green manure crop into the rice–wheat system as well as the retention of their residues increased soil C status, improved soil properties and maximized grain yields.