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Competing Interests: None

Competing Interests: None

Competing Interests: None

Competing Interests: None

Competing Interests: None

Suicide is a complex phenomenon, often linked to environment. Despite the identification of many social, cultural, economic and political correlates and risk factors, psychiatry continues to argue for curative solutions based on the reductionistic biomedical model, rather than support public health measures to manage the larger sociocultural, economic and political context. While psychiatry and curative medicine help many people, survival of the human body is best explained by the materialist explanation that locates the variation in health and longevity to tangible resources. There is no single, simple or straightforward solution to reducing population suicide rates; specific mental health interventions are unlikely to impact secular trends in the rates of suicide.

Background: There is a dearth of recent data on the relationship between nutritional status and intellectual development among children in India. To determine whether such a relationship exists, we studied children in a rural area of Tamil Nadu., Methods: We stratified villages in Kaniyambadi block, Tamil Nadu, and recruited consecutive children who satisfied the study criteria. We assessed nutritional status by measuring height and weight and recording chronological age, and calculated indices weight-for-age, height-for-age, weight-forheight and their Z scores. We assessed intellectual development using the Indian adaptation of the Vineland Social Maturity Scale. We used a case-control framework to determine the relationship and logistic regression to adjust for common confounders., Results: We recruited 114 children between the ages of 12 and 72 months. Z score means (weight-for-age -1.36; height-for-age -1.42; weight-for-height -0.78) were much less than 0 and indicate undernutrition. Z score standard deviations (weight-for-age 1.04; height-for-age 1.18; weightfor- height 1.06) were within the WHO recommended range for good quality of nutrition data suggesting reduced measurement errors and incorrect reporting of age. The frequency distributions of population Z scores suggest high undernutrition, wasting and medium stunting. A tenth of the population (9.6%) had values to suggest borderline/below average intelligence (social quotient <89). Lower height-forage, height-for-age Z score and weight-for-height Z score were significantly associated with a lower social quotient. These relationships remained statistically significant after adjusting for sex and socioeconomic status using logistic regression., Conclusion: Chronic undernutrition, wasting and stunting and their association with lower intellectual development demand an urgent re-assessment of national food policies and programmes.

Arriving at a medical diagnosis is a complex process, which requires clinical skill. However, the need for clear decisions has to be balanced by an acceptance of the ambiguity of many clinical situations. Complex presentations often require probabilistic inferences rather than presumed diagnostic certainty. The demands, logic and process of clinical diagnosis are highlighted. The multiple aspects of clinical reality and the impact of gold standards, nature of evidence and dichotomous disease/no disease categorization are discussed. The importance of population characteristics and context in diagnostics and prediction are emphasized. The statistics of agreement, Bayesian approach, certainty and risk, hazards and pitfalls, common errors, audit and the influence of commercialization on diagnosis are addressed. There is a need to formally teach the art and science of medicine and to transfer clinical skill rather than hope that such skills will be automatically imbibed during training.

Background: Sexual dysfunction, common in general medical practice, is under-recognized and inadequately managed resulting in significant morbidity and reduction in quality of life. We examined the nature, prevalence, clinical features and explanatory models of illness among men with sexual dysfunction in a general healthcare setting., Methods: We recruited 270 consecutive men attending a general health clinic. Participants were evaluated using a structured interview. The International Index of Erectile Function-5, the Chinese Index of Premature Ejaculation-5, Short Explanatory Model Interview and the Revised Clinical Interview Schedule were used to assess sexual dysfunction, explanatory models and psychiatric morbidity., Results: Premature ejaculation and erectile dysfunction were reported by 43.0% and 47.8% of men, respectively. The most common perceived causes were loss of semen due to masturbation and nocturnal emission. Popular treatments were herbal remedies and resources used were traditional healers. The factors associated with erectile dysfunction were diabetes mellitus, financial stress, past history of psychiatric treatment and common mental disorders such as depression and anxiety; those associated with premature ejaculation were common mental disorders, older age and financial debt. Sexual dysfunctions and concerns were under-diagnosed by physicians when compared to the research interview., Conclusion: There is a need to recognize sexual problems and effectively manage them in general medical settings. The need for sex education in schools and through the mass media, to remove sexual misconceptions, cannot be under-emphasized., (Copyright 2014, NMJI.)

Some recent studies from Vellore, Tamil Nadu, on dementia have been published in international journals as part of international data, analysis and interpretation. They have also been published separately employing local perspectives and analysis. The different results and interpretations of these two approaches to the same data suggest the need for independent work and study of the local reality to inform national public health policies.

Background: We examined the nature, prevalence and explanatory models of sexual concerns and dysfunction among women in rural Tamil Nadu., Methods: Married women between 18 and 65 years of age, from randomly selected villages in Kaniyambadi block, Vellore district, Tamil Nadu, were chosen by stratified sampling technique. Sexual functioning was assessed using the Female Sexual Function Index (FSFI). The modified Short Explanatory Model Interview (SEMI) was used to assess beliefs about sexual concerns and the General Health Questionnaire-12 (GHQ-12) was used to screen for common mental disorders. Sociodemographic variables and other risk factors were also assessed., Results: Most of the women (277; 98.2%) contacted agreed to participate in the study. The prevalence of sexual dysfunction, based on the cut-off score on the FSFI, was 64.3%. However, only a minority of women considered it a problem (4.7%), expressed dissatisfaction (5.8%) or sought medical help (2.5%). The most common explanatory models offered for sexual problems included an unhappy marriage,stress and physical problems. Factors associated with lower FSFI included older age, illiteracy, as well as medical illness and sexual and marital factors such as menopause, poor quality of marital relationship, history of physical abuse and lack of privacy., Conclusion: The diagnosis of female sexual dysfunction needs to be nuanced and based on the broader personal and social context. Our findings argue that there is a need to use models that employ personal, local and contextual standards in assessing complex behaviours such as sexual function., (Copyright 2014, NMJI.)

Background: There is a paucity of data on the use of alcohol in urban slums of southern India., Methods: We screened 2811 men for alcohol use via a household-level census in an urban slum in Vellore, Tamil Nadu, and interviewed 220 age- and area-matched pairs of men drinkers and non-drinkers to examine factors associated with alcohol use. Alcohol Use Disorder Identification Test (AUDIT), a standard instrument, was used to assess risk levels of drinking of 354 drinkers. Prevalence rates were calculated using age- adjusted direct standardization. Odds ratios (ORs) of drinking status and higher-risk drinking were calculated using conditional logistic regression and ordinal logistic regression, respectively., Results: Among all men, we estimated that 46.1% consumed alcohol and 31.4% were hazardous drinkers (19% increased-risk, 7.7% high-risk and 4.7% dependent drinkers). Factors associated with alcohol use were: manual labour occupations (OR 2.08); presence of a common mental disorder (OR 1.50) and smoking (OR 2.08); while Muslim religion was protective (OR 0.43). Factors associated with higher-risk alcohol use were: being reported as a non-drinker during the census (OR 3.96); presence of a common mental disorder (OR 3.83); smoking (OR 1.78); drinking before legal age of 21 years (OR 2.71); spending more than `100 per day on alcohol (OR 6.17); and mainly drinking Indian-made foreign liquor (OR 5.45)., Conclusion: High prevalence of hazardous drinking and the factors associated with it suggest the need for population- wide interventions and further investigations to effectively reduce hazardous alcohol use and its harmful effects., (Copyright 2013, NMJI.)

Background: Violence against women may have an impact on infant and child mortality. We aimed to determine whether domestic violence is a risk factor for infant and child death., Methods: Eighty infant and child deaths (under 5 years of age) were identified from a central register of a comprehensive community health programme in rural southern India; controls were matched for age, gender and street of residence., Results: Domestic violence during the lifetime (OR 2.63, 95% CI 1.39-4.99), which was severe (OR 4.00, 95% CI 2.02-7.94) and during pregnancy (OR 5.69, 95% CI 2.03-15. 93) and father's smoking status (OR 3.81, 95% CI 1.92-7.55) were significantly related to infant and child death while immunization being completed for age (OR 0.04, 95% CI 0.01-0.19) and having at least one boy child in the family (OR 0.29, 95% CI 0.14-0.59) were protective. These variables remained statistically significantly associated with outcome after adjusting for other determinants using conditional logistic regression., Conclusion: There is evidence for an association between domestic violence in mothers, and infant and child death., (Copyright 2013, NMJI.)

Background: The recognition rates of anxiety and depression in general medical settings, despite the significant prevalence of such presentations, are low. Psychiatrists argue that the recognition and management of these conditions by physicians is less than optimal in primary care and general practice. We did this study to gain insights into physicians' perspectives on anxiety, depression and somatization, the conceptual models they employ and the practical problems they face in managing such patients in general medical settings. METHODS. Focus group discussions (FGDs) were conducted with family and primary care physicians. The FGDs for physicians were tape recorded and transcribed, verbatim. The views of psychiatrists working in liaison clinics were also ascertained., Results: Family and primary physicians admitted to a high prevalence of patients who present with medically unexplained symptoms. They noted the co-occurrence of psychosocial stress. All physicians working in general medical settings admitted to difficulty in separating anxiety, depression and somatic presentations because of milder, less distinct syndromes and overlapping symptoms. They argued that it was difficult to use the current three-category division and that a more complex classification would be time-consuming and impractical in primary care., Conclusion: Psychiatric classifications for use in primary care should consider the different context and employ physicians' perspectives rather than push specialist concepts and criteria., (Copyright 2012, NMJI.)

Extreme policies of prohibition or the current permissive strategies are counterproductive and call for a nuanced public health approach that integrates both the regulation of availability of alcohol as well as helps in rigorously enforcing the law.

Background: There is a dearth of data on the hazardous use of alcohol in rural India., Methods: We examined the nature, prevalence and factors associated with hazardous use of alcohol among men in a rural community in southern India. We used stratified sampling to select subjects from the Kaniyambadi block and employed 'AUDIT', a standard instrument, to assess the use of alcohol., Results: The prevalence of life-time use, use in the past year and hazardous use of alcohol was 46.7%, 34.8% and 14.2%, respectively. Using Indian made foreign liquor (OR 20.51; 95% CI 8.81-47.75) and living in a village which brewed illicit alcohol (OR 2.82; 95% CI 1.39-5.72) were risk factors for hazardous use while education (OR 0.39; 95% CI 0.21-0.72) was protective. These factors remained significantly associated with hazardous use after adjusting for age and education using logistic regression., Conclusion: The relationship between the availability of illicit and commercial alcohol and its hazardous use suggests the need for an alcohol policy which takes into account health and economic issues and also implements the law to prevent the negative impact of problem drinking.

Background: There are little data from India on the long term follow up of patients with alcohol dependence who have undergone a de-addiction programme. A cohort of patients who completed a detoxification and de-addiction programme based on the Alcoholics Anonymous model were followed up for a period of 5 years., Methods: A cohort design was used. A community outreach programme of a de-addiction centre was the setting for the study. One hundred and eighty-two patients who completed a detoxification and de-addiction programme based on the Alcoholics Anonymous model were followed up. Sobriety at 5 years' of follow up was the outcome measure., Results: One hundred and fifty-one (83%) patients were followed up at 5 years. The majority (90; 59.6%) did not change their alcohol consumption and a small minority (25; 16.5%) remained completely sober over the 5-year period. Sobriety at 1 year was significantly associated with complete abstinence at 5 years (chi2 = 53.8; df = 1; p < 0.001). More patients coming from distant places (RR 0.84; 95% CI: 0.71, 0.98; p < 0.03) and those with health workers in their localities (RR 0.81; 95% CI: 0.68, 0.96; p < 0.01) were completely abstinent. These variables were also significantly associated with sobriety even after adjusting for other confounders using logistic regression., Conclusion: . The results of the 5-year outcome are modest. More patients coming from distant places and those with health workers in their localities remained completely abstinent suggesting the possible role of the individual's motivation and the need for continued community support in maintaining sobriety.

Background: Studies from India have reported high rates of suicide. We aimed to understand the social and cultural factors that modulate the risks related to suicide., Methods: Focus group discussions were conducted with community health workers (1 group) and members of the public (6 groups). In-depth interviews were also conducted with 5 people who had attempted suicide and survived. The interviews were tape-recorded and transcribed verbatim. The results were summarized and analysed using standard procedures., Results: The most common causes for suicide were interpersonal and family problems, and financial difficulties. Mental illness was also reported as causal. All 5 subjects who had attempted suicide mentioned marital and family discord as the cause. The majority of the general population and all the subjects who had attempted suicide were not aware of any community and support services for the prevention of suicide., Conclusion: Our study reveals that people perceived suicide as an option to overcome interpersonal, family and financial stress among normal individuals as well as those with mental illness. Healthcare providers should place greater emphasis on educating the general public regarding the policies and services available for suicide prevention.

Diverse frameworks, models and 'cultures' of depression have been postulated and promoted by psychiatrists, the pharmaceutical industry, general practitioners, primary care psychiatrists and the general population. Psychiatrists and the pharmaceutical industry endorse the medical model while general practitioners and the public subscribe to social and psychological frameworks. These models are partial truths and should be viewed as complementary rather than competitive, some more valid in a specific context than others. The issues that need to be resolved include: (i) reexamination of the validity of the psychiatric diagnosis of depression in the primary care context; (ii) a review of the adequacy of a single label of depression to describe the diverse human context of distress; (iii) acknowledging the problems of using a symptom checklist in diagnosing depression; (iv) recognizing the need for psychosocial diagnostic formulations which clearly state the context, personality factors, acute and chronic stress and coping; (iv) highlighting the fact that antidepressant medication should be reserved for severe forms of distress; (v) re-emphasizing the need to manage stress and alter coping strategies in the treatment of people with such presentations; (vi) de-emphasizing medicalization of all forms of personal and social distress; (vii) focusing on other underlying causes of human misery including poverty, unmet needs and lack of rights. Clinically, there is a need to look beyond symptoms and explore personality, life events, situational difficulties and coping strategies in order to comprehensively evaluate the role of vulnerability, personality factors and stress in the causation of depression.

Background: Symptoms related to the reproductive tract and symptoms of psychological distress are commonly seen in women living in South Asia. This study aimed to determine the association, if any, between symptoms related to the reproductive tract and mental health among women in rural southern India., Methods: The study was conducted in a community setting of a comprehensive community health programme in a development block in rural southern India. It was a cross-sectional survey with a nested case-control study. The main outcome measure was the probability of mental distress as assessed by the Tamil version of the General Health Questionnaire-12 (GHQ)., Results: Of the 622 subjects recruited, 150 (24.4%) complained of at least one symptom related to the reproductive tract. The commonest symptom was vaginal discharge (17.5%). Significantly higher scores on the GHQ were associated with the presence of many current and past symptoms related to the reproductive tract, and receiving treatment for the same, even after adjusting for age, education, current marital status and type of house, using multiple regression analysis. GHQ scores were positively correlated with a higher number of current and past symptoms. Significantly higher scores were also associated with greater knowledge about prevention of sexually transmitted diseases and reproductive tract infections. Being currently married and educated were significant protective factors. A nested case-control study was done with the presence of a current common mental disorder as the outcome. Symptoms and other factors dated prior to this outcome were considered potential risk factors. Logistic regression models were developed. The presence of a symptom related to the reproductive tract for more than one month (OR 3.6; 95% CI 1.8, 7.2) and a history of similar symptoms over the past year (OR 2.2; 95% CI 1.3, 3.7) were risk factors for the development of common mental disorders. Higher education (OR 0.5; 95% CI 0.3, 0.7) and being currently married (OR 0.2; 95% CI 0.1, 0.6) were protective factors., Conclusion: The cross-sectional data suggest an association between symptoms pertaining to the reproductive tract and psychological distress. The results of the nested case-control study suggest that symptoms related to the reproductive tract are risk factors for common mental disorders, while education and being currently married are protective factors.

Background: Patients with unexplained somatic symptoms are commonly seen in primary care. We assessed the explanatory models and common mental disorders in patients with unexplained somatic symptoms attending a primary care facility in a rural area of south India., Methods: One hundred consecutive patients diagnosed to have unexplained somatic symptoms attending a primary care facility were examined. The Tamil version of the Revised Clinical Interview Schedule was used to assess common mental disorders and the Tamil version of the Short Explanatory Model Interview was used to assess their explanatory models., Results: Ninety-eight patients thought that their problem was serious. Sixty-nine, 41 and 40 claimed that it affected their work, family and social lives, respectively. Forty-two of the patients believed in black magic. Forty-four patients satisfied the ICD-10 PC criteria for common mental disorders. Depression was the commonest diagnosis (63.6%). Patients with psychiatric diagnoses admitted to emotional problems (chi2 = 46.9; p < 0.001), and felt that their problems affected their family (chi2 = 38.5; p < 0.001), social life (chi2 = 28.6; p < 0.001) and work (chi2 = 34.4; p < 0.001). More patients who satisfied criteria for psychiatric diagnosis felt that their problems were moderate or very serious (chi2 = 21.5; p < 0.001) and they feared they might become disabled or die (chi2 = 12.2; p < 0.001). Psychiatric syndromes were significantly associated with belief in black magic (chi2 = 7.01; p < 0.01). These associations remained statstically significant after adjusting for age, gender, literacy and socioeconomic indices using logistic regression., Conclusion: The majority of patients held strong beliefs regarding the physical nature of their complaints, believed In the serious nature of the problem and feared disability or death. There is a need to elicit specific explanatory models regarding the nature of illness in patients who present with somatic symptoms without organic causes. Understanding the patient's perspectives is a prerequisite for providing the necessary treatment and to dispel fears.